First name

Last name

Phone number Alternate phone number

Email address

Address of the crop

City State Zip code

Mailing address (if different from crop address)

City State Zip code

Is the property within the Salem and Keizer city limits?

No
Yes
Not sure

What is your relationship to this property?

Owner and occupant
Rental property (landlord)
Renter
Other
Landlord contact information (if applicable)

Type of crop

How much (for instance '2 trees' or '3 acres' or '300 pounds')

Location of plants on the property

Crop height (feet)

Lowest produce height (feet)

What time of year is the crop usually ripe? [select] Late May Early June Mid June Late June Early July Mid July Late July Early August Mid August Late August Early September Mid September Late September Early October Mid October Late October Early November Middle November

Does the crop have any fungus, disease or pest issues?

No
Yes
Describe

Has the crop been sprayed this year?

No
Yes
Describe

How did you hear about Salem Harvest? [select] Neighbor Salem Harvest web site Friends of Salem Saturday Market Marion-Polk Food Share Salem Harvest volunteer LifeSource Natural Foods Newspaper Facebook Farmers Ending Hunger Flyer Craigslist Congregation Other urban harvesting group Friend Other Web search

Is there anything else you would like us to know? (e.g. preferred path to the crop, dogs, steep slope, power lines, parking, etc.)

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