ARIZONA CROP IMPROVEMENT ASSOCIATION
		The University of Arizona						App. No.:
		2120 E. Allen Road
		Tucson, AZ 85719					FOR ACIA USE ONLY
		Phone (520) 305-3586*FAX (520) 305-3587
						Date Received
APPLICATION FOR FIELD INSPECTION						Membership $
Applicant:						Member Name
Address :			Phone:				$0.00	@$/Acre
						acres	$
City:		State/Zip:		County:		Total $	$0.00
Grower :
				Phone
Mailing Ad						Email:
			City	State	Zip
1.  This application is limited to a single grower, crop kind, variety and certified seed class produced.  It must be signed by the applicant.
2.  Separate applications are preferred for each field.
3.  Verification of stock seed source and eligibility is required.  Submit certification tags or other documentation showing eligibility, or applicant's
own lot number.  Grower who plant more than one seed lot of one variety must indicate where each lot was planted.
				Crop :				Acres:
	Legal Description
				Variety :
				Seed class planted				Produced
				Seedstock source:
				Seedstock lot #:				year gro
				Previous crops 20				20
				Planting date:				Phyto.  #:
				The undersigned is a member of Arizona Crop Improvement Association or applies
				for membership with the application.  Such membership signifies agreement to
				abide by the standards, procedures and regulations of the Association in producing
				conditioning and handling of the seed crop applied for.
				Signature				Date
FOR INSPECTOR USE ONLY
Maturity					Date inspected
Isolation					Class approved
Roguing					Acres approved
Other varieties					Acres disapproved
Other crops					Remarks
Weeds
					Inspector
ACIA-FIA-05/12 v2.2