Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1697800130255.pdf (Dominica)
NEW CROP FARMER APPLICATION FORM- CERC DOMINICA EMERGENCY AGRICULTURAL LIVELIHOODS AND CLIMATE RESILIENCE PROJECT The CERC is part of the Emergency Agricultural Livelihoods and Climate Resilience Project (DEALCRP) designed to assist New Farmers access inputs during the COVID-19 pandemic.

For Administrative Use only Application reference number: (MPID No.)

Beneficiary Region: 1.

Applicant details a.Name of applicant First: Middle: Last: Alias: b.
Gender c. D.O.B Male Female D____ M_____ Yr__________ d. Group membership Name of Group/s: Contact Info (Other Representatives): e. Agricultural region (Main plot) North North East Central East West South South East Location of farm/s: Agricultural region/Catchment: a.

Address Residential: Notable Landmark: Tel- Mobile: Other: Email: Crop Livestock Fisheries Other (specify): Services Accepted: Training in a. Pesticide use ; b.

Farming techniques c. Inputs Extension Officer support ; None Other: b.
Contact Information c. Main source of income (current/last job) i.

Background experience with MAF services Please tick all that apply DO NOT WRITE IN GREY SPACES a.

Crop Farmer i.

S ii.

M iii.

L 1.1 Applying as: (S- small {0.25- 2 acres}; M- Medium {>2 <5 acres}; L- Large {>5 acres}; GHC- GH Commercial { Small Greenhouse -(60*30 - 1800 sq ft);Medium Greenhouse- 2 Greenhouse (>3600 < 5400 sq ft); Large Greenhouse- 3 Greenhouses (>5400 sq ft).

iv.

GHC S M L Systems: b.
Cropping [2] Banana/Plantain; [3] Root Crops; [4] Horticulture; [5] Tree Crops [1] Vegetable; Note: Note: 1.2 Cultivated acreage (record size of holding): GIS: Yes No H1 [ ] H 2 [ ] H 3 [ ] H 4 [ ] 1.4 Identity (Documents to be presented on registration) Identity: (SS; PP; DL) __________________ Produce Sellers License (PSL):________________ Grey Spaces For Administrative Use Only Identity: Verified SS: ______________________ PP: _______________________ DL: ______________________ BRN/Producer Sellers License: __________________ Documents registration presented upon SS PP DL Yes No Yes No 2.
Asset Ownership Status – Crop Farmer Reported for Main Plot Verified 3.

Information on the land/activity (Main plot): Reported Verified 3.1Total Surface Area 3.2.Total Cultivable Land 3.3.Total Cultivated Land 3.4 Location 3.5 Main Crop [1] Veg; [2] Banana/Plantain; [3] Root Crops; [4] Horticulture; [5] Tree Crops 3.6 Post Maria Land Validation Participated Y [ ] N [ ] Y N 4.

How did you come to know of the project?

Newspaper Word of Mouth Social Media Radio Flyer 5.
Nationality: _______________________ 6.

Country of Birth: _______________________ 2.1.Land tenure (for Crop farmers): 1.

Individually Owned land 2.

Long term lease 3.

Inheritance/Gift 4.

Communal Yes No Land Reg.

No:[ ] Means of Verification: Documents submitted legitimate: Yes No Field Visit: No Yes D__/M __ /Yr __ GIS: Yes No 2.2.

Proof of Land Tenure Yes No A.

Title B.


Lease C. Will or legal D. Kalinago council authorization Means of Verification: Documents submitted legitimate: Yes No E. Other (specify) ______________ Field Visit: No Yes D__/M __ /Yr __ 2 BASELINE-ENVIRONMENTAL AND SOCIAL CONCERNS For multiple lots insert holding no.

in Yes, No or NA column MPID No.


: C R O P A ND L I V E S T O C K B A S E L I N E I N F O R M A T I O N E NV I R O NM E NT AL C O N C E R N S 1 Is your farm bordering with any of the following environmentally sensitive areas?

a. Forests, National Parks, Wildlife Reserves b. Rivers or other waterways (mangroves, wetlands, lakes) c. Waitukubuli National Trail Is your farm bordering any: 2. a.

Public main road or Highway b.

Private Secondary road c. Public Secondary road d. Farm road or Feeder road 3.
Which is your main water supply a. Rainwater b. River/ stream/Underground c. DOWASCO 4.

Main source of energy used on farm a. Fossil Fuels b.

Wind c. Solar d. Hydro e. Other YES NO N/A ***** ***** ***** 1.2.3.4.5.

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Which of the following water conservation methods do you practice ***** ***** a. Drip Irrigation b.

Harvesting rainwater c. Mulching d. Other (specify) e. None 1.2.3.4.5.

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Which of the following soil conservation methods do you practice ***** ***** ***** a. Contour farming b. Terracing c. Planting grasses (Vetiver) d. Reduce tillage e. Wind Breaks f. Drainage g. Live Barriers e. Other (specify) f. None 1.2.3.4.5.

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Which of the following weed control methods are you applying ***** ***** ***** a. Manual weed control b. Spraying with herbicides c. Livestock grazing d. Mulching e. Brush Cutter e. A combination (specify) f. Other g. None 8.
Which farm waste management do you apply a. Composting b.

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Which of the following categories of Organic and Inorganic pesticides/ plant nutrients do you use (tick and name all that apply) Products a. Herbicide (Name: ) b. Insecticides (Name: ) c. Fungicides (Name: ) d. Fertilizer (Name: ) e. Other chemical application (Name: ) Organic Pesticides Inorganic Pesticides f. None 10.

Do you use Protective Personal Equipment 11.


Based on observations, how would you describe bee population in your area ***** Yes ***** No ***** ***** ***** ***** ***** ***** ***** ***** (circle a, b, c, or d): Increased since Maria a. b.

Same, since Maria c. Decreased since Maria d. Can’t say ***** ***** ***** 12.

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Have you received training in the use of pesticides Yes No Climate Resilience Baseline Yes No Never heard of it 14.

Have you ever received training on climate resilient/climate smart farming?

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Do you practice any drought resistant farming practices?

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Do you need support/assistance with rain water harvesting?

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Is your farm insured against impact of natural hazards?

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How would you describe your farming techniques I. Livestock Farmer (circle a, b, c, or d…): ii.

Crop Farmer: a.

Battery caged system b.

Deep litter system g. Other c.Free range d. Tethering h.None e. Semi Intensive/Intensive f. Cut and carry Indigenous a. b.

Modern c. Traditional d. Environmentally Sustainable e. Other 19.

Number of persons in household: _____ 20.

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of persons under age 5___ 6-18 ___ 65+ ______in household Social Safeguards 21 i.
Are you a beneficiary of any Government social programmes/social protection programme?

Y N ii.

Name of programme/s: 22.

Do you have access to financial assets/credit?

a. bank b. credit union c. Farmer’s Cooperative d. Other ___________________________ Name of Staff Member completing Form: Name of Extension Officer Reviewing Form: Name: Name: Signature: Date Signature: Date 4