High Plains Food Coop

High Plains Food Coop Member-Producer Registration

Thank you for your interest in becoming a producer member of High Plains Food Coop. High Plains Food Coop customers and producers are interested in local foods and products produced with sustainable practices that demonstrate good stewardship of the environment. This form upon approval will register you to sell products within the High Plains Food Coop. Please read the HPFC Standards and the Membership Information Statement and then fill out and submit the form below.

SECTION 1: GENERAL INFORMATION
First Name:		Last Name:
First Name 2:		Last Name 2:
Producer ID: **		Business Name:
** Choose a unique 5-character Producer ID to represent your operation. Use alphabetic or numeric characters only. ID should NOT include any special characters. (i.e. NO dashes)
Address:		City:
State:		Zip:
County:		Phone:
E-mail:
Website:	http://
Select your Preferences here. You will be able to change these preferences from your member area later if necessary.
Delivery Type:		Delivery Location:
Preferred Method of Payment:		Check PayPal online
Please choose a username and password which you will use to log in to the member pages. Your password must be at least 6 characters.
Username:		Password:
Please confirm your password:
SECTION 2: MEMBERSHIP FEES (Please download and read the available Member Information Statement before investing.)
Charter Member: Purchase online with PayPal: $103.30 for one share of common stock — valid thorugh July 1st or first 150 members. Or receive cash/check discount: $100.00 for one share of common stock. Voting Member: Purchase online with PayPal: $103.30 for one share of common stock — plus $20.91 annual fee thereafter, waived the first year. Or receive cash/check discount: $100.00 for one share of common stock — plus $20.00 annual fee thereafter, waived the first year. Non-voting Member (Not currently available): Purchase online with PayPal: $41.50 annual non-voting member fee. Or receive cash/check discount: $40.00 annual non-voting member fee.
How You Heard:		If other, please specify:
YES! I‘m interested in volunteering to help in the High Plains Food Cooperative.
SECTION 3: PRODUCTS & PRACTICES
List what you intend to sell through HPFC. (if applicable) (e.g. meats, grains, jellies, crafts; also note if you have any heritage breeds)

Describe your farming, processing and/or crafting practices. (if applicable)

Describe your pest and disease management system. (if applicable)

Describe your herd health and productivity management. (if applicable) (i.e. do you use any hormones, antibiotics, and/or steroids)

Describe your feeding practices. (if applicable) (grass-fed only, free-range, feed-lot, etc.)

Describe your soil and nutrient management. (if applicable) (Do you compost, use fertilizers, green manures or animal manures?)

Describe your water usage practices. (if applicable) (If you irrigate, describe how - e.g. deep well, surface water, etc., and explain how you conserve water or use best management practices. Describe how you are protecting your water source from contamination/erosion).

Describe your conservation/land stewardship practices. (if applicable) (e.g., do you plant windbreaks, maintain grass waterways, riparian buffers, use green manures for wind erosion, plant habitats for birds, improve soil quality, etc.)

Describe any additional information and/or sustainable practices about your operation that would be helpful to a potential customer in understanding your farm or operation better. (e.g. if you are raising any heritage animals you might list breeds or list varieties of heirloom seeds. List the percentage of High Plains ingredients in your processed items).

List your food liability insurance coverage, both general and product-related, as well as any licenses and tests that you have available. (if applicable)

SECTION 4: ORGANIC PRODUCERS
List which products you are selling as organic. (if applicable)

List certifying agency's name and address: (if applicable)
Certifying Agency's Phone: (if applicable)		Certifying Agency's Fax: (if applicable)
Do you have available for inspection a copy of your current organic certificate? (if applicable)			Yes No
I affirm that all statements made about my farm and products in this application are true, correct and complete and I have given a truthful representation of my operation, practices, and origin of products. I understand that if questions arise about my operation I may be inspected (unannounced) by HPFC. If I stated my operation is organic, then I am complying with the National Organic Program and will provide upon request a copy of my certification. I have read all of HPFC's producer standards and fully understand and am willing to comply with them. I agree
I acknowledge that I have read and understand the High Plains Food Cooperative Member Information Statement.
Please enter this code in the box:

**Please mail your voting or non-voting membership fees check to:
High Plains Food Cooperative, 1678 US Hwy 36, St. Francis, KS 67756
or use the Paypal buttons on the next page.