Dairy Producer2016 Animal Care Participation Form

Contact Information

Primary Contact:      Farm name:      Address:      City:       State:     Zip Code:      Phone:       Email:      Farm type: Freestall:       Pasture/open lot:       Tie stall/Stanchion:       Average annual production (lbs):

Additional Organization Contacts

Contact #2:      Address:      City:       State:     Zip Code:      Phone:       Email:      

Certification of Participation

I hereby agree to abide by the requirements for membership in the FARM animal care program, including but not limited to adopting the animal and farm maintenance guidelines set forth in the FARM animal care manual, including any revisions in the guidelines that FARM may develop. I recognize my farm will be subject to on-farm evaluations and may be subject to third-party verification to ensure the program’s integrity. I hereby grant permission to FARM to carry out such third-party verification as described in the “Program Integrity Through Third-Party Verification” section of the FARM manual. I further understand that the information collected will be held in the strictest confidence except that FARM may use the data in an aggregated form in a manner that does not disclose the identity of my farm.

Signature: __________________________________________________ Date: _____________________