CRFM Stallholder Application Form CRFM Stallholder Application Form Thank you for your interest in becoming a stallholder at the Capital Region Farmers Market (CRFM). The Capital Region Farmers Market operates Saturday mornings from 7:30 am – 12:00 pm, at Exhibition Park in Canberra (EPIC). Please note that NO casual ‘drop-ins’ are permitted to sell at the CRFM. APPLICATION PROCESS 1. If invited by the CFRM Manager, complete and submit this application form. Submitting this application form does not necessarily mean you will be accepted as a stallholder, only that you have progressed to the next stage of the application review process. (a) All applicants MUST read and acknowledge their acceptance of and willingness to comply with the CRFM Market Rules (on page 6 of this application) as part of the application process. (b) Upon completion of this application form, please forward to the CRFM Manager, along with other documentation requested. 2. The CRFM Manager will advise all applicants of the CRFM Management Committee decision. Successful applicants will be advised of the procedure to be followed to then participate in the Market. 1 Stallholder Information2 General Information3 Producer Information4 Insurance5 Certification / Registration6 Booking Requirements7 Declaration Stallholder's Name First Last Company Name*ABNPostal Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Farm/Business Location Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Mobile Phone*Business PhoneEmail* Website FaceBook Page Instagram Account Local Government Area*Farm Distance* Which best describes you*Egg ProducerFruit GrowersHorticultureMeat ProducersProcessors Form (any cooked, processed or value-added foods, breads, cakes, sweets, cordials, dips, jams, etc)Vegetable GrowersTertiary Producer (Ready To Eat Food)Stallholder AgentProducer CategoryCheck all that apply Primary Producer - All products grown, reared, caught on producer’s land. e.g. fruit, vegetables, meat, eggs. Secondary Producer - Anyone processing or adding value. e.g. cheese, wine, cakes, oil, small goods/charcuterie Tertiary Producer - For admittance into Food Court. i.e. prepared, ready-to-eat food Brief Background of Your Business OperationPlease provide a brief background summary of the operation of your business and the produce/product for sale using the appropriate fields below: Overview of your businessWhat you can offer the MarketDescription of products/produce offeredMeans/methods of production - how and where do you grow/produce your products?Source/s of production inputsOther retail outlets used and/or markets attended Egg ProducerInformation sheet for Egg Producers The Market Management Committee needs to know what each stallholder is currently producing and it needs to approve any new products in advance of their being offered for sale. This form identifies the basic information required to be provided by a stallholder to verify authenticity.What land area do you have - in hectares?*Farm/business location address (if different from first page) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Please attach a plan showing the layout of your property and free-range areasACT Health Notification NumberNSW Food Authority Registration No.If located in NSWTotal number of hens on your property in the month immediately prior to the date of this application*Hen Varieties*Total egg production (dozen) for the the month immediately prior to the date of this application*Name/s of feed suppliers*New stock: Do you breed young stock?*YesNoDo you purchase young stock?*YesNoHow many per annum?*Please list suppliers*I declare that*All of the above information is true and correct;All subsequent additions will be reported to the Market Management (i.e. Hen Varieties, Numbers, Age, expected to start laying);I am aware that the Market Management may require verification through inspection and or production of receipts; Yes, I agree to have reviewed and understand all of the above declaration details Fruit GrowerInformation sheet for Fruit Growers - (including all fruits, berries etc) The Market Management Committee needs to know what each stallholder is currently producing and it needs to approve any new products in advance of their being offered for sale. This form identifies the basic information required to be provided by a stallholder to verify authenticity.Address of orchard/groveIf different from first page Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country List of fruit grown by you*List all the fruit you intend to sell at the market.*What land area do you have - in hectares?*Please attach a plan showing the layout of your property with different crops or varieties identifiedACT Health Notification NumberNSW Food Authority Registration NumberIf located in NSWDo you have cool-room facilities?*YesNoPlease advise cool-room capacity*Please provide names of suppliers of fertilizers, pesticides and other*Please provide the current tree/bush numbers and varieties*i.e. Variety, Area/number, When planted, Expected start of harvest, Expected end of harvest. I declare that*All of the above information is true and correct;All subsequent plantings after the acceptance of all applications will be reported to the Market Management (i.e. Variety, Area/number, When planted, Expected start of harvest, Expected end of harvest.);I am aware that the Market Management may require verification through inspection and or production of receipts; Yes, I agree to have reviewed and understand all of the above declaration details HorticultureInformation sheet for Horticulture - Plants, trees, flowers, herbs for planting, etc The Market Management Committee needs to know what each stallholder is currently producing and it needs to approve any new products in advance of their being offered for sale.This form identifies the basic information required to be provided by a stallholder to verify authenticity.List ALL products will you offer at the Market.*What land area do you have - in hectares?*Address of Property/Growing AreasIf different from first page Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Attach a plan showing the layout of your property and growing areas with different crops or varieties identified.Please provide information on the products you are currently growing for the Market.*i.e. Variety, Area/number, When planted.I declare that*All of the above information is true and correct; All subsequent products after the acceptance of all applications will be reported to the Market Management (i.e. Variety, Area/number, When planted);I am aware that the Market Management may require verification through inspection and or production of receipts; Yes, I agree to have reviewed and understand all of the above declaration details Meat ProducerInformation sheet for Meat Producers The Market Management Committee needs to know what each stallholder is currently producing and it needs to approve any new products in advance of their being offered for sale. This form identifies the basic information required to be provided by a stallholder to verify authenticity.List ALL products will you offer at the Market.*ACT Health notification numberNSW Food Authority Registration No.If located in NSWWhat land area do you have - in hectares?*Please attach a plan showing your property and grazing areasFarm/business location addressIf different from first page Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Do you have a certified production/processing facilities?*YesNoWhat is the address?If different from above (or first page) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Names of main feed suppliers*Name of Abattoirs and/or butchers*Please provide information on the stock currently on the property*i.e. Stock types, Number, Age, Expected killing this yearI declare that*All of the above information is true and correct;All subsequent purchasing and breeding will be reported to the Market Management (i.e. Stock types, Number, Age, Expected killing schedule);I am aware that the Market Management may require verification through inspection and or production of receipts; Yes, I agree to have reviewed and understand all of the above declaration details ProcessorsInformation sheet for Processors The Market Management Committee needs to know what each stallholder is currently producing and it needs to approve any new products in advance of their being offered for sale. This form identifies the basic information required to be provided by a stallholder to verify authenticity This category covers ANY cooked, processed or value-added foods, makers of bread, cakes, sweets, cordials, dips, jams, etcList ALL products will you offer at the Market.*ACT Health notification numberNSW Food Authority Registration NumberIf located in NSWWho are your suppliers? Please list your main suppliers of primary ingredients*Who are your local/regional suppliers? Please list ingredients.*What production premises do you have?*e.g. Stores, cool-room, etcAre your premises a Health Certified Kitchen?*YesNoStreet address of production facilitiesIf different from first page Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country I declare that*All of the above information is true and correct;I am aware that inspections of the production site and stall equipment will be a prerequisite for approval;All subsequent products to those above will be submitted for approval by the Market Management before they can be sold;I am aware that the Market Management may require verification through inspection and or production of receipts; Yes, I agree to have reviewed and understand all of the above declaration details Vegetable GrowersThe Market Management needs to know what each stallholder is currently producing and it needs to approve any new products in advance of their being offered for sale.This form identifies the basic information required to be provided by a stallholder to verify authenticity.List of vegetables grown by you*List ALL vegetables will you offer at the Market.*What land area do you have - in hectares?*Please attach a plan showing the layout of your property with different crops or varieties identifiedACT Health Notification NumberNSW Food Authority Registration NumberDo you have cool-room facilities?*YesNoPlease provide names of suppliers of fertilizers, pesticides and other*Please list the produce currently in the ground*i.e. Product, Area/number planted, When planted, Expected start of harvest, Expected end of harvest.Please list the produce currently in storage*i.e. Product, When was it harvested, Quantity held, Where is it stored?Continual Planting Plan*i.e. Product, Frequency of planting, Area/number planted, Seasons planted?Abandoned crops*Please list every time the you have abandoned a crop [it died and/or was ploughed in]. i.e. Product, Area/Number planted, Date planted, Abandoned date.New Plantings*You will need to advise us every time you plant a new item [other than items covered by the Continual Planting Plan above]. i.e. Product, Area/number planted, Date planted, Expected time of harvest, Expected end of harvestI declare that*All of the above information is true and correct;All subsequent plantings after the acceptance of all applications will be reported to the Market Management (i.e. Product, Area/number planted, When planted, Expected start of harvest, Expected end of harvest.);I am aware that the Market Management may require verification through inspection and or production of receipts; Yes, I agree to have reviewed and understand all of the above declaration details I declare that*All of the above information is true and correct;All subsequent plantings after the acceptance of all applications will be reported to the Market Management (i.e. Product, Area/number planted, When planted, Expected start of harvest, Expected end of harvest.);I am aware that the Market Management may require verification through inspection and or production of receipts; Yes, I agree to have reviewed and understand all of the above declaration details Tertiary ProducerInformation sheet for Ready To Eat Food The Market Management Committee needs to know what each stallholder is currently producing and MUST approve any new products in advance of their being offered for sale. This form identifies the basic information required to be provided by a stallholder to verify authenticity and needs to be completed in addition to the CRFM Stallholder Application Form. Important: Ready To Eat Food can only be sold in the Ready To Eat Food area of the CRFM. Only approved products can be sold at the CRFM.Do you produce the Ready To Eat food that you wish to sell at the Market?*YesNoDo you produce any of your ingredients?*YesNoPlease indicate what ingredients you produce yourself*(e.g. meat, vegetables, fruit)List in detail, the Ready To Eat Food items you wish to sell at the CRFM. Please include primary ingredients and suppliers.*List any local/regional ingredients used.*Are you currently selling food ready to eat at other locations or venues?*YesNoPlease provide details*Are you prepared to be a weekly/full-time stallholder?*YesNoHave you completed a Food Handler’s Course or equivalent?*YesNoIs your production facility a Health Registered Kitchen?*YesNoDo you have HACCP Certification, or equivalent?*YesNoDo you have a Food Safety Plan?*YesNoEquipment All equipment must be appropriately licensed. Electrical connections must be certified by a qualified electrician: TESTED & TAGGED. Gas is permitted, however stallholders must have a fire extinguisher on hand and follow safe OH&S practices.List all equipment you intend to use on your stall*Do you need Power?*YesNoHow many leads?*12310 amp or 15 amp?*10 amp15 ampI declare that*All of the above information is true and correct;All subsequent products to those above will be submitted for approval by the Market Management before they can be sold (for example, if an apple or jam producer decided to sell their own cheese or cakes, they must seek approval).I am aware that the Market Management may require verification through inspection and or production of receipts; Yes, I agree to have reviewed and understand all of the above declaration details Stallholder AgentThe Market Management Committee must approve all stallholder agency arrangements (i.e. (anyone who sells anything they do not grow or process themselves) including detail on products and quantities to be offered. For all agencies the stallholder MUST provide: 1. This form is to be fully completed by the Stallholder 2. The “Agency Form” to be completed in detail and signed by the actual producer of products to be offered. Note: No products may be sold under any agency arrangement without the specific prior approval of the Market Management Committee. Such action would be a breach of the rules and could lead to expulsion from the Market.List the products you will offer at the Market*Please list the current producers for whom you are an agent*i.e. Product, Supplier, Address, Contact numberI declare that*All of the above information is true and correct;I am aware that the Market Management may require verification through inspection and/or production of receipts; Yes, I agree to have reviewed and understand all of the above declaration details InsuranceAll Producers MUST HAVE market insurance covering: • $20 million public liability, and • $20 million product liability. Evidence must be shown prior to allocation of a stall.Do you have your own market insurance?*YesNoHow much public liability?How much product liability?Name of InsurerExpiry Date If applicable, please provide a copy of your current market insurance Drop files here or HealthAre you registered with ACT Health / NSW Health?*YesNoHow are you registered?*Low RiskMedium RiskHigh RiskPlease provide a copy of your current ACT Heath Registration*Do you have any other Health registrations?*eg. VehicleYesNoPlease provide other Health registration information*Please provide a copy of any other Health registrations* Drop files here or Organic/Biodynamic/Gluten Free/OtherAre you registered as Organic/Biodynamic/Gluten Free or Other?* Organic Biodynamic Gluten Free Other Not registered Please provide a copy of any Organic/Biodynamic/Gluten Free/Other certifications Drop files here or ChemicalDo you use chemicals/sprays on your crops?*YesNoPlease provide a current copy of your ChemCertYou will also be required to show the Compliance Committee your Spray Diary during any farm inspection. How regularly do you plan on attending the Market?*Where possible, fulltime stallholders will be offered a regular site. No sites are permanent. Full-time Stall - Attending weekly.Fortnightly Stall- Regular non-weekly attendance for no less than 12 months of the year.Seasonal StallDo you need Power?*Very few powered sites are available. All electrical equipment MUST BE appropriately licensed. Electrical connections MUST BE certified by a qualified electrician. Electrical connections and appliances must be tested and tagged annually. Ensure your equipment is SAFE.YesNoDo you need Storage?*There is a waiting list for storage due to limited capacity. See CRFM Rules for regulations and fees for storage.YesNoFeesPlease refer to the CRFM Market Rules on our website for the current fee structure. Important InformationPlease read the following important information below and acknowledge your review of these points by ticking the checkbox at the bottom. All stallholders are required to conform to the CRFM Market Rules including a code of conduct as determined by the Market Management Committee from time to time. The CRFM Market Rules are displayed on the CRFM website at: www.capitalregionfarmersmarket.com.au A ‘once-only’ $50 Administrative Processing Fee is payable before your first attendance. A ‘once-only’ $100 initial set-up and Website Maintenance Fee is also payable before your first market attendance.There will be no occupation of a stall site until: The application has been approved by the Market Management Committee; An appropriate site is available and has been allocated, and You have been advised of the above by the Market Manager. Please wait to be advised whether or not your application has been approved and the number and location of your site.Once approved, please report to the Market Manager when you first attend the market to confirm your site allocation.I confirm that I have reviewed and understand all of the above important information* Yes, I agree to the above statements DeclarationPlease read the following declaration details below and acknowledge your agreement by ticking the checkbox at the bottom. I declare that: I agree to comply with the CRFM Market Rules as determined and applied by the Market Management Committee and will ensure that I remain compliant with all CRFM Market Rules and updates and/or amendments by regularly reading the CRFM Market Rules detailed on the Market website;I have read the CRFM Market Rules on the website and understand that this is an authentic Farmers Market and that the authenticity and integrity of the Market is of paramount importance to its approved producers and the Market Management Committee;I acknowledge that should I breach the CRFM Market Rules, I may be suspended and/or terminated as a stallholder, following an appropriate investigation. In particular, where, after investigation, and in the opinion of the Market Management Committee, a stallholder has been found to be not operating within the CRFM Market Rules, the CRFM Management Committee reserves the right to permanently expel them from the Market;I hold and will maintain current permits and licences required by the ACT and Federal governments (including relevant Fair Trading laws, labeling laws, weight and measures laws and Health registration requirements) as appropriate; I hold all necessary certifications claimed in respect of products on offer (e.g. organic and/or other appropriate certification); All products to be sold in the Market will at all times be approved by and comply with the conditions determined and applied by the Market Management Committee. Only approved products/produce as listed on the CRFM website can be sold at the Market; I will advise the Market Management Committee of any significant change in circumstances declared in this application;I agree to representatives of the Market Management Committee visiting my premises/property (or the premises/property of a producer for whom I am the approved agent) at a mutually acceptable time during normal business hours;I will display signs identifying my trading name, product prices and weights and measures as well as Green ‘producer’ signs for producers products, Orange ‘agency’ signs for agency products and Purple signs for ‘organic’ produce;I will maintain the necessary insurance cover whilst attending the Market;I acknowledge the right of the CRFM Management Committee to verify any/all information provided by me;I acknowledge that stallholders vacating the CRFM to attend other markets are required to pay their site fee in full;I understand that site fees must be recieved by the Thursday prior to a market to avoid a late payment admin fee of $20.I confirm that I have reviewed and understand all of the above declaration details* Yes, I agree to all of the above statements Photo and video consent form.*By ticking YES, you give permission for the Market and its suppliers to take imagery and videos of stallholders and their products to be used for marketing purposes. We strongly encourage all stallholders to agree, as it’s a great marketing opportunity to get your brand out there. YesNoPhoneThis field is for validation purposes and should be left unchanged.
