Vendor chemical declaration form
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COMMODITY VENDOR DECLARATION
Please print clearly.
3rd edition, March 2005
SERIAL NUMBER
5 Chemicals applied on your property (attach list if necessary)
Trading name of producer or storage facility Vendor’s name (if different) Vendor’s address
(FULL ADDRESS INCLUDING POSTCODE)
List all chemicals (excluding fertilisers) applied to crops within 100 metres of the crop from which this commodity was derived, or which have placed that crop in a spray drift risk area, as follows: a. from seedling emergence, or last cut, to this harvest for the fodder supplied; or b. from commencement of flowering to harvest for grains supplied.
Crop/situation Chemical applied Rate/Ha Application date WHP and/or EI
Tel no. Vendor’s contract no. (if applicable) End user’s trading name and address Commodity Delivery period from
DAY MONTH YEAR
Fax
End user’s contract no. Tonnes represented by this declaration to
DAY MONTH YEAR
6 Neighbours’ Crops (attach list if necessary)
Answer 1A or 1B as applicable.
1A This commodity is ex producer:
If applicable, please tick the relevant box, complete the following details and then go to Question 2.
List all neighbours crops within 100 metres of the crop from which this commodity was derived, or which have placed that crop in a spray drift risk area, as follows: a. from seedling emergence, or last cut, to this harvest for the fodder supplied; or b. from commencement of flowering to harvest for grains supplied.
Crop Approx. harvest month
Direct ex paddock Property name Shire
Ex farm storage Harvest date
DAY MONTH YEAR
Paddock I.D./s
7 Has the crop been grown on a property with a chemical residue status classification?
1B This commodity is ex multi vendor storage:
If applicable, please complete the following details and then go to Question 2.
Storage location Release number
2
Yes Silo/pad no.
No
If Yes, give details
8 Having kept appropriate records and after making the necessary inquiries,
Does the property on which the commodity is grown, or storage facility in which the commodity is stored carry accreditation under an independently audited QA program which includes chemical residue management for the commodity being supplied?
Yes No If Yes, give details:
NAME OF PROGRAM ACCREDITATION NO.
If the answer to Question 2 is Yes, go straight to Question 8. If the answer is No, please refer to the explanatory notes.
3 Was the commodity tested for chemical residues by a NATA accredited laboratory and test
method?
Yes No
If Yes, attach details of testing results on delivered product
4 Chemical applied to the commodity whilst under your control (attach list if necessary)
List all agricultural chemicals (excluding fertilisers) applied to the commodity while it was under your control, as follows: a. from seedling emergence, or last cut, to this harvest for fodder; b. from commencement of flowering to harvest for grains; and c. all post harvest treatments.
Chemical applied Rate/Ha or tonne Application date WHP and/or EI
I/we truthfully believe that: a. all chemicals applied to the crops or commodity specified in this declaration, by me/us or by other persons on my/our behalf during the growing of the crops and/or during the storage of the commodity are disclosed, where required, in the responses to Questions 4 and 5 of this declaration; b. all chemicals were applied in accordance with their registered labels and at rates not exceeding the maximum rates set out on those labels; and c. any Withholding Periods and/or Export Intervals set out on the labels of the chemicals applied to the crop or commodity whilst under my control have been observed and, where required, are specified in the response to Question 4 of this declaration. d. the commodity supplied does not contain any materials that are prohibited for use as feeds for ruminant livestock (cattle, sheep, goats, etc) under state/territory legislation, specifically in regard to animal by-products. I/We further declare that I/we have read and understood the explanatory notes and declare that the information in this document is true and correct. Signed by the representative of the organisation supplying this commodity who is responsible for the production and/or storage of this commodity prior to dispatch to the above end user. Name Signature Position Date
DAY MONTH YEAR
COMMODITY VENDOR DECLARATION
Please print clearly.
3rd edition, March 2005
SERIAL NUMBER
5 Chemicals applied on your property (attach list if necessary)
Trading name of producer or storage facility Vendor’s name (if different) Vendor’s address
(FULL ADDRESS INCLUDING POSTCODE)
List all chemicals (excluding fertilisers) applied to crops within 100 metres of the crop from which this commodity was derived, or which have placed that crop in a spray drift risk area, as follows: a. from seedling emergence, or last cut, to this harvest for the fodder supplied; or b. from commencement of flowering to harvest for grains supplied.
Crop/situation Chemical applied Rate/Ha Application date WHP and/or EI
Tel no. Vendor’s contract no. (if applicable) End user’s trading name and address Commodity Delivery period from
DAY MONTH YEAR
Fax
End user’s contract no. Tonnes represented by this declaration to
DAY MONTH YEAR
6 Neighbours’ Crops (attach list if necessary)
Answer 1A or 1B as applicable.
1A This commodity is ex producer:
If applicable, please tick the relevant box, complete the following details and then go to Question 2.
List all neighbours crops within 100 metres of the crop from which this commodity was derived, or which have placed that crop in a spray drift risk area, as follows: a. from seedling emergence, or last cut, to this harvest for the fodder supplied; or b. from commencement of flowering to harvest for grains supplied.
Crop Approx. harvest month
Direct ex paddock Property name Shire
Ex farm storage Harvest date
DAY MONTH YEAR
Paddock I.D./s
7 Has the crop been grown on a property with a chemical residue status classification?
1B This commodity is ex multi vendor storage:
If applicable, please complete the following details and then go to Question 2.
Storage location Release number
2
Yes Silo/pad no.
No
If Yes, give details
8 Having kept appropriate records and after making the necessary inquiries,
Does the property on which the commodity is grown, or storage facility in which the commodity is stored carry accreditation under an independently audited QA program which includes chemical residue management for the commodity being supplied?
Yes No If Yes, give details:
NAME OF PROGRAM ACCREDITATION NO.
If the answer to Question 2 is Yes, go straight to Question 8. If the answer is No, please refer to the explanatory notes.
3 Was the commodity tested for chemical residues by a NATA accredited laboratory and test
method?
Yes No
If Yes, attach details of testing results on delivered product
4 Chemical applied to the commodity whilst under your control (attach list if necessary)
List all agricultural chemicals (excluding fertilisers) applied to the commodity while it was under your control, as follows: a. from seedling emergence, or last cut, to this harvest for fodder; b. from commencement of flowering to harvest for grains; and c. all post harvest treatments.
Chemical applied Rate/Ha or tonne Application date WHP and/or EI
I/we truthfully believe that: a. all chemicals applied to the crops or commodity specified in this declaration, by me/us or by other persons on my/our behalf during the growing of the crops and/or during the storage of the commodity are disclosed, where required, in the responses to Questions 4 and 5 of this declaration; b. all chemicals were applied in accordance with their registered labels and at rates not exceeding the maximum rates set out on those labels; and c. any Withholding Periods and/or Export Intervals set out on the labels of the chemicals applied to the crop or commodity whilst under my control have been observed and, where required, are specified in the response to Question 4 of this declaration. d. the commodity supplied does not contain any materials that are prohibited for use as feeds for ruminant livestock (cattle, sheep, goats, etc) under state/territory legislation, specifically in regard to animal by-products. I/We further declare that I/we have read and understood the explanatory notes and declare that the information in this document is true and correct. Signed by the representative of the organisation supplying this commodity who is responsible for the production and/or storage of this commodity prior to dispatch to the above end user. Name Signature Position Date
DAY MONTH YEAR