SCS VeriFlora® Application - Producers © 2009. Scientific Certification Systems

General Company Information
  1. Legal company name:(as it would appear on the VeriFlora®certificate)

  1. USA Company/Subsidiary (if different):

  1. Primary company address:

Street:
City, State/Province, Zip/Postal Code:
Country:
Website:
  1. Primary company contact person:
/
  1. Billing contact person:

Name:
Title: / Name:
Title:
Phone: / Phone:
Cell: / Cell:
E-mail: / E-mail:
Fax: / Fax:
FARM / PRODUCTION FACILITYNAME(S)
  1. List all Farms / Production Facilities, or portions thereof, covered by thisApplication
(Please identify each facility by a separate name.)
List:
Provide complete information for each farm/facility in Annex 1, Questions A-V.
Certification Services INFORMATION
  1. Multi-site certification: (Companies with multiple locations may opt to administer the SCS VeriFlora CertificationProgram centrally, or have each site administer its own program; please indicate if you have reached a decision).
Administer centrally Administer individually Not Sure
Comments:
  1. Desired date/time frame for audit:

  1. Desired date/time frame for securing certification:

  1. Nearest major airport (and distance to your facility from airport):

  1. Are there other companies in your supply chainthatmay wish to pursue certification?
List:
  1. Who may we thank for referring you to Scientific Certification Systems (SCS)?

  1. Additional information or comments:

AFFIRMATION
I affirm that the information provided herein is true and correct to the best of my knowledge, and that I am duly authorized to sign this application. Should our company decide to pursue certification, I agree to supply any information that is deemed necessary for the audit of the operation and/or products to be certified, as well as to comply withall relevant standards.
Name: / Signature: ______
Title: / Date:
Please complete Annex 1 below for each farm/facility
covered by this application.
Please return this application to:
Jennifer Watters, Certification Associate, Sustainable Agriculture
E-mail:
Please fax signature page to: 510.452.8001
Thank you for choosing SCS.

ANNEX 1

Complete one form for each farm/production facility to be included in the scope of this evaluation.

Three forms are provided below.

If you have more than three farm/production facilities, please contact SCS for additional forms.

Main Company Name:

FARM / PRODUCTION FACILITY #1
  1. Farm / Production Facility name:
Farm / Production Facility address:
Street:
City, State/Province, Zip/Postal Code:
Country:
  1. Farm / Production Facility primary contact person:

Phone: / Cell:
Email: / Title:
  1. List all products covered under the scope of this evaluation:
Cut Flowers
List categories:
Potted Plants
List categories:
Plugs & Liners
List categories:
  1. Container types / sizes(Potted plants only):

  1. Do you make bouquets at this facility?(Cut flower producers only) Yes No

  1. Estimated annual production:
/ # Stems: # Plants: Other (specify):
  1. No. of fields:
/ Size: Acres Hectares
  1. No. of Greenhouses:
/ Size: Acres Hectares
  1. Distance between Fields:
/ Miles Kilometers
  1. Percent of plants or flowers in greenhouse: Percent of plants or flowers inopen field:

  1. Estimated gross annual sales ($US):

  1. Describe your sales distribution channels: (e.g.,sell to wholesalers, importers, or retailers)

  1. Total number of employees at this facility:
Full-time: Part-time: Seasonal / Temporary:
  1. Are subcontractors used to perform tasks at this facility? Yes No
If yes, for what tasks?
  1. How would you assess Farm / Production Facility’s level of preparedness for the audit?
New to this process Knowledgeable Written procedures drafted
  1. List the potential work hazards in your operation:

  1. Current Third-Party Certification, if applicable: (e.g., Organic, Sustainable)

Claim: / Certifier: / Reg. #:
  1. Are hazardous chemicals (synthetic or botanical) used at this facility? (check all applicable)
Pest/Disease Control Cleaning Other (Specify: )
  1. How many agrochemical storage sites?

  1. Name of Pest Management Specialist:
Staff-member Contracted
Phone:
Fax:
E-mail:
  1. Name of Pest Management Authority (State, County, Fed. Agency):

Address:
Contact:
Phone:
Fax:
E-mail:
  1. Site Map / Photos:Please attach site map or photos identifying property boundaries, buildings, waste /compost sites, wells and major water bodies, including monitoring locations (if applicable), significant natural features, and ecologically sensitive areas on and off site. Check as appropriate:
SITE MAP ATTACHED SITE MAP MAILED PHOTOS ATTACHED PHOTOS MAILED
File name(s):
FARM / PRODUCTION FACILITY #2
  1. Farm / Production Facility name:
Farm / Production Facility address:
Street:
City, State/Province, Zip/Postal Code:
Country:
  1. Farm / Production Facility primary contact person:

Phone: / Cell:
Email: / Title:
  1. List all products covered under the scope of this evaluation:
Cut Flowers
List categories:
Potted Plants
List categories:
Plugs & Liners
List categories:
  1. Container types / sizes (Potted plants only):

  1. Do you make bouquets at this facility? (Cut flower producers only) Yes No

  1. Estimated annual production:
/ # Stems: # Plants: Other (specify):
  1. No. of fields:
/ Size: Acres Hectares
  1. No. of Greenhouses:
/ Size: Acres Hectares
  1. Distance between Fields:
/ Miles Kilometers
  1. Percent of plants or flowers in greenhouse: Percent of plants or flowers in open field:

  1. Estimated gross annual sales ($US):

  1. Describe your sales distribution channels: (e.g., sell to wholesalers, importers, or retailers)

  1. Total number of employees at this facility:
Full-time: Part-time: Seasonal / Temporary:
  1. Are subcontractors used to perform tasks at this facility? Yes No
If yes, for what tasks?
  1. How would you assess Farm / Production Facility’s level of preparedness for the audit?
New to this process Knowledgeable Written procedures drafted
  1. List the potential work hazards in your operation:

  1. Current Third-Party Certification, if applicable: (e.g., Organic, Sustainable)

Claim: / Certifier: / Reg. #:
  1. Are hazardous chemicals (synthetic or botanical) used at this facility? (check all applicable)
Pest/Disease Control Cleaning Other (Specify: )
  1. How many agrochemical storage sites?

  1. Name of Pest Management Specialist:
Staff-member Contracted
Phone:
Fax:
E-mail:
  1. Name of Pest Management Authority (State, County, Fed. Agency):

Address:
Contact:
Phone:
Fax:
E-mail:
  1. Site Map / Photos: Please attach site map or photos identifying property boundaries, buildings, waste /compost sites, wells and major water bodies, including monitoring locations (if applicable), significant natural features, and ecologically sensitive areas on and off site. Check as appropriate:
SITE MAP ATTACHED SITE MAP MAILED PHOTOS ATTACHED PHOTOS MAILED
File name(s):
FARM / PRODUCTION FACILITY #3
  1. Farm / Production Facility name:
Farm / Production Facility address:
Street:
City, State/Province, Zip/Postal Code:
Country:
  1. Farm / Production Facility primary contact person:

Phone: / Cell:
Email: / Title:
  1. List all products covered under the scope of this evaluation:
Cut Flowers
List categories:
Potted Plants
List categories:
Plugs & Liners
List categories:
  1. Container types / sizes (Potted plants only):

  1. Do you make bouquets at this facility? (Cut flower producers only) Yes No

  1. Estimated annual production:
/ # Stems: # Plants: Other (specify):
  1. No. of fields:
/ Size: Acres Hectares
  1. No. of Greenhouses:
/ Size: Acres Hectares
  1. Distance between Fields:
/ Miles Kilometers
  1. Percent of plants or flowers in greenhouse: Percent of plants or flowers in open field:

  1. Estimated gross annual sales ($US):

  1. Describe your sales distribution channels: (e.g., sell to wholesalers, importers, or retailers)

  1. Total number of employees at this facility:
Full-time: Part-time: Seasonal / Temporary:
  1. Are subcontractors used to perform tasks at this facility? Yes No
If yes, for what tasks?
  1. How would you assess Farm / Production Facility’s level of preparedness for the audit?
New to this process Knowledgeable Written procedures drafted
  1. List the potential work hazards in your operation:

  1. Current Third-Party Certification, if applicable: (e.g., Organic, Sustainable)

Claim: / Certifier: / Reg. #:
  1. Are hazardous chemicals (synthetic or botanical) used at this facility? (check all applicable)
Pest/Disease Control Cleaning Other (Specify: )
  1. How many agrochemical storage sites?

  1. Name of Pest Management Specialist:
Staff-member Contracted
Phone:
Fax:
E-mail:
  1. Name of Pest Management Authority (State, County, Fed. Agency):

Address:
Contact:
Phone:
Fax:
E-mail:
  1. Site Map / Photos: Please attach site map or photos identifying property boundaries, buildings, waste /compost sites, wells and major water bodies, including monitoring locations (if applicable), significant natural features, and ecologically sensitive areas on and off site. Check as appropriate:
SITE MAP ATTACHED SITE MAP MAILED PHOTOS ATTACHED PHOTOS MAILED
File name(s):

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