Effective Date
12/17/14
Form # A-1
Producer Information &
Label Claim Application
Please check a box for form use:
New Alliance Member
Alliance Member Renewal
Label Claim Only
2015
This Old Farm Meats & Processing
9572 W CR 650 S Colfax, IN 46035
(765) 324-2161
www.thisoldfarminc.com
Farmer’s/Producer’s Name
Business (Farm) Name
Business Address, City, State, Zip and County
E-mail/Website Address
Home Phone Number, Cell Phone Number, Fax Number
Is this Farm within 400 miles of This Old Farm (USDA’s definition of Local) yes _________________
no______________________
Type of Business: (circle)
______________________
Individual
Family
LLC
Partnership
Corporation
Other:
All Product listing- List all that apply:
Product
Month (s) Available
Volume
How is the product
labled?____________________________________________________________________________________
___________________________________
__________________________________________________________________________________________
_______________________________________________________________
For Meat/Cheese/Dairy Products
Check all designations that apply, N/A if not applicable
Animals are 100% grass fed.
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Animals are on pasture or free range.
No use of synthetic fertilizers, pesticides or herbicides.
No use of hormones or antibiotics
Pork: Gestational Crate Free
No use of preservatives
None of the above
Is your Product, circle all that apply:
A. Certified Organic – Please attach a copy of your Organic Certification Certificate to this form.
B. Transitional Organic
C. Not certified, but raised organically
D. Not certified, but raise naturally
E. Conventional
How do you amend your soil?
How do you control parasites/ insects?
How do you control unwanted weeds?
Do you use any feed additives or injectables to supplement your animals' normal diet? (Please note that
these are often included in the ration.)
Do you use any hormones or antibiotics to maintain your animals' health or promote growth?
How do you deal with your animals' sickness/disease?
Animal Surroundings (list percentage of each used):
__________ Grass Fed ______________ Free Range ____________ Feed Lot
________________Pasture
How long have your animals been in your care prior to processing?
Animals
Month(s)/Year(s) in
possession
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Farm of Origin
For Vegetable/Plant Products
Check all designations that apply, N/A if not applicable
Certified Organic Seed stock or starts
Use of untreated seed stock or plantings
Use of heirloom open-pollinated seeds
No use of synthetic fertilizers, pesticides or herbicides
Native Indiana plants
None of the above
Is your Product, circle all that apply:
A. Certified Organic – Please attach a copy of your Organic Certification Certificate to this form.
B. Transitional Organic
C. Not certified, but raised organically
D. Not certified, but raise naturally
E. Conventional
F. GAP Certified – Please attach a copy of your GAP certification
G. GAP Certification in progress
How do you amend your soil?
How do you control parasites/ insects?
How do you control unwanted weeds?
For Value Added Goods & Products
Check all designations that apply, N/A if not applicable
No use of preservatives, artificial flavorings or colors
Packaging is recyclable, biodegradable and/or reusable
At least 90% of the ingredients used are Certified Organic, Certified
Naturally Grown or from “Pledge No” operations
Product Produced/Manufactured locally?
50% locally sourced ingredients
50% of goods were grown by vendor
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Product Information (Ingredients, animal parts, other pertinent
information)________________________________________________________
__________________________________________________________________________________________
_______________________________________________________________
__________________________________________________________________________________________
_______________________________________________________________
Please list items you are interested in producing that you do not currently produce.
Good(s)
Month(s) Available
Ingredient(s)
Attachments needed (circle all that are included):
Feed formulation for all stages of growth
Organic Certification
GAP Certification
Current Market List with Copy of Last Invoice
Other___________________________________________
Affidavit
Applicants certifies, under penalties of perjury, that all the information set forth in this application
for permit is true and complete to the best of his/her knowledge.
Print Name
Signature
Date
This is informational only and does not constitute a contract between yourself and This Old Farm, Inc.
Please note that there is no right or wrong answers. We will utilize the information to develop pricing levels
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for your product as well as label claims. All information must be correct. This form is an application for
onboarding your locally raised farm products as part of our Alliance of This Old Farm Producers and does
not guarantee sale.
Comments:
Office Use Only:
_____ Received Application
_____ Entered into Spreadsheet
_____ Assigned an Alliance Member #
_____ File Created/File
Meet the Farmer and Farm Where Your Meat Came From
Name of Farmer______________________________ Name of
Farm_____________________________________________
Address____________________________________________________________
_____________________________________________
Phone____________________________________________
Fax_________________________________________________________
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Website___________________________________________ Facebook
Page__________________________________________
Year Farm Started________________________ Generational Farm, Which
Generation__________________
At Our Farm We
Raise______________________________________________________________
_______________________
___________________________________________________________________
_______________________________________________
___________________________________________________________________
_______________________________________________
___________________________________________________________________
_______________________________________________
Are you certified or have special
accreditation________________________________________________________
___________________________________________________________________
_______________________________________________
___________________________________________________________________
_______________________________________________
Any special notes you would like the consumers to know about you or your farm
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
_____________________________
___________________________________________________________________
________________________________________________
___________________________________________________________________
________________________________________________
Please email this form along with any pictures of you, your family and/or your
farm to kristy@thisoldfarminc.com, or you may bring in or mail to: This Old
Farm Inc. at 9572 W County Road 650 S, Colfax, IN 46035. Please call 765-3246
2161 if you have any questions.
As always, thank you for being part of the Alliance and helping to bringing
Good Local Food to our Consumers!
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