CERTIFICATION APPLICATION–Sustainable Agriculture (SAN)
可持续农业（农场）经营认证申请表Farm FSC认证
Please tick the relevant box(es) : 请于相关框内打勾完成相关选项。
1.General Information 基本信息（应填写中英文） | ||||||||
Client 客户 | ||||||||
Farm name农场名称 | ||||||||
Company name公司名称 | Legal registration N°营业执照注册号 | |||||||
Mailing address地址 | ||||||||
Tel/fax电话传真 | Email邮箱 | |||||||
Type of legal organization法律实体的类型 | ||||||||
Company or Corporation (with shareholders)公司或股份公司 Government 政府组织 Family farm 家庭农场 | Individual company (limited shares) 个体有限公司 Leased farm 租赁农场 Other. Specify其他类型: Indicate here. | |||||||
Contact person for certification 认证联系人 | Owner/Legal representative 农场主/法人代表 | |||||||
Name姓名 | Name姓名 | |||||||
Position职务 | Position职务 | |||||||
Tel/fax电话传真 | Tel/fax电话传真 | |||||||
Email邮箱 | Email邮箱 | |||||||
Sales representative 销售代表 | ||||||||
Name姓名 | Tel/ fax电话传真 | |||||||
Position职务 | Email邮箱 | |||||||
2. Farm information农场信息 | ||||||||||
Farm location 农场位置 | ||||||||||
Town or city城镇 | Municipality市 | District地区 | ||||||||
County县 | Province or Dpt.省 | Country国家 | ||||||||
Physical address具体地址 | Please provide further directions on how to get to the farm.提供更详细的位置，以方便到达
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Coordinates (decimal degrees) 坐标（10进制） | ||||||||||
纬度Latitude: | 经度Longitude: | |||||||||
位置说明Location of reading: (e.g. in plantation area, warehouse, main office, etc.种植区、仓库，主要办公点的等): | ||||||||||
Is the farm certified with any other organization该农场是否通过其它组织的认证? | ||||||||||
(Specify说明) | ||||||||||
Has the farm been certified Rainforest Alliance Certified TM ? 该农场是否通过了雨林联盟认证TM？ | ||||||||||
Yes | (Specify说明) | No | ||||||||
Are you the owner or administrator of other farms not included in the scope of the audit有否不包括在范围的其他农场? | ||||||||||
Yes | (Specify) | No | ||||||||
Is part of the farm subleased农场是否有部分被转租? | ||||||||||
Yes | Land use土地利用情况 | Area(hectares)面积(公顷) | No | |||||||
4. Agricultural production to be certified拟认证的农作物 | ||||||
Common name通用名① | Scientific name 学名 | Variety (ies)品种② | Product quality产品质量③ | Harvest period采收期④ | Average volume (kg/ha)平均产量 | Total volume (kg)总产量⑤ |
填写说明： ①②If it includes more than one crop/variety, must be indicated each in separate rows; and totalized如果不止一种作物/品种,须单独显示行和总量 ③Specify, for instance, quality degrees. Regarding coffee, SHG, etc. 说明,如质量度。关于咖啡口味等 ④Specify harvest months and year 收获月或年 | ||||||
5. Actual land use土地实际使用情况 | |||||||||||||||
Production area to be certified认证区域 | 面积Area (ha) | 基础设施Infrastructure area | Area (ha) | ||||||||||||
Please itemize the type and extension of ecosystems of high value present within the farm’s limits请逐条列出农场范围内高价值生态系统的类型和范围 | |||||||||||||||
Ecosystem type 生态系统类型 | Area面积 | Is it located within a conservation area是否在保护区内? | |||||||||||||
1 | (ha公顷) | ||||||||||||||
2 | (ha公顷) | Yes | No | ||||||||||||
n | (ha公顷) | Yes | No | ||||||||||||
Other types of areas其他类型区域 | (ha公顷) | Total汇总 | (ha) | ||||||||||||
What is the distance to the nearest conservation area距离较近的保护区是什么? | Indicate here.说明位置 | ||||||||||||||
Do you have aerial photographs or satellite images? (Attach)有否航拍照片或卫星图形？（请附图） | |||||||||||||||
Yes | No | From which year(s)何时的? | |||||||||||||
Do you keep land use records since 1999 or before? Do you have a map or sketch你在1999年或更早的时候保留了土地利用记录吗？你是否有相关的地图或是草图？ | |||||||||||||||
What regeneration/reforestation activities have you implemented in the farm after 1999；你在1999年之后推行过哪些更新/造林活动？? | |||||||||||||||
Indicate here.表明位置 | |||||||||||||||
Indicate the types and quantity of infrastructure existing in the farm请详述农场内现有基础设施的类型和数量 | |||||||||||||||
Offices办公室 | Nursery苗圃 | ||||||||||||||
Warehouse/Storage仓库/ 贮藏间 | Seed treatment area育种区 | ||||||||||||||
Laboratory实验室 | Collection center 集货区 | ||||||||||||||
Workshop车间 | Processing area 加工区 | ||||||||||||||
Cafeteria for the employees餐厅 | Ovens, boilers烤箱、锅炉 | ||||||||||||||
Housing住房 | Waste treatment area废弃物处理区 | ||||||||||||||
Airport 机场 | Waste water treatment system废水处理系统 | ||||||||||||||
Fuel Station燃料站 | Irrigation System灌溉系统 | ||||||||||||||
Pumping Station抽水泵 | Wells 水井 | ||||||||||||||
Other. Specify其它，请详述 | |||||||||||||||
6. Information on the labor organization劳工组织信息 | |||||
Do collective organizations exist 有否劳工组织? | Yes | No | |||
Type of organization组织的类型 | Total members组织人数 | ||||
Contact person联系人 | Name姓名 | Position职务 | |||
Tel/fax电话传真 | Email邮箱 | ||||
7. Information on the providers供应商信息 | ||||
Do you have service providers?有否服务供货商？ | Yes | No | ||
Indicate the type of service 服务类型 | ||||
Contact person联系人 | Name姓名 | Position职务 | ||
Tel/fax电话/传真 | Email邮箱 | |||
8. Traceability. List of buyers of certified product可追溯性，认证产品的购买商清单 | ||||||||||||||
Agricultural production 农产品 | ||||||||||||||
Name名称 | 地址Location (Country国家, City城市) | 联系方式Contact (Name姓名, email邮箱) | 年采购量Annual quantity (ton吨) | |||||||||||
9. Facilities located outside the farm[1] 农场1外面的辅助地点/设施 | ||||||||||||||
Nº | Description描述 | Estimated t ime of transfer (hours) from the farm to the facilities从农场到到这些辅助地点/设施的大致时间(小时) | ||||||||||||
1 | ||||||||||||||
2 | ||||||||||||||
3 | ||||||||||||||
4 | ||||||||||||||
5 | ||||||||||||||
10. Monitoring and Evaluation Form[2] 监测和评估表 | |
General Information 基本信息 | |
| 1 Average water consumption in common operations (liters): 正常情况下平均用水量 (升) Irrigation灌溉 Processing 加工 2 Treated residual waters in common operations (liters): 正常情况下废水处理量(升) 3 Agrochemicals purchased annually (kg) 每年购买农药量(公斤): I类Class I II类Class II 其它Others 4 Total protected hectares受保护的总面积: 5 Total hectares under conservation保护区总面积 6 N° of species identified in farms农场内确定的物种数量（可选）: Flora植物： Fauna动物： 7 Total meters of river beds or bodies of water permanently protected: 河床或永久保护的水体总长度 8 Total number of permanent local workers: 长期雇佣的当地工人总数 Men男性: Women女性: 9 Total number of permanent foreign workers: 长期雇佣的外来工人总数 Men男性: Women女性: 10 Total number of temporary local workers:临时雇佣的本地工总数 Men男性: Women女性: 11 Total number of temporary foreign workers: 临时雇佣的外来工总数 Men男性: Women女性: 12 Number of minors benefiting from support for their education: 受教育支助的未成年人数 13 Do workers have access to potable water in the work site劳作场所工人可否喝到饮用水? YES NO 14 Is the workers salary greater than $2 for the daily full time work day工人全天工作的日工资是否高于2美元? YES NO 15 N° of serious accidents during the last year去年严重事故数: 16 Current certified production (kg): 当前的认证产品量 17 Production sold as certified (kg):作为认证产品销售的产品量 18 Percentage of certified products sold in the market:认证产品的销售比例 Domestic国内 International国外 Indicate here % Indicate here % | |
Date: | |
11. Instructions to complete the form表单填写说明 | ||||
· The information provided in this application and in the attached documents is true, reliable and sufficient. 在本申请表中提供的信息和附加文件是真实、可靠和足够的 · Please complete this form electronically or else submit it printed or typed. 请填写此表格以电子方式或其他印刷或输入提交它 · Should you have any questions, please contact our office. 如果您有任何问题,请联系我们的办公室。 · You must fill out the form completely; otherwise it will not be processed. 你必须完整填写表格,否则它将不被处理 · Please submit this form to mychen71@163.com 请提交此表格至mychen71@163.com · Once applied, this document will give you as the basis of plan and quotation 本文档一旦应用, 将作为给你计划与报价的依据 | ||||
Approved in representation of (Name of Organization/)制作人 | ||||
填表人Producer： | 日期Date： | |||
Full name of the representative or person authorized授权代表全名 | 职位Position: | |||
(In order to process this application, you may sign and scan it or send an e-mail to mychen71@163.com indicating you approve this application). 如有可能的签署和扫描，请发送电子邮件至mychen71t@163.com | ||||
希望审核日期dates for assessments | 希望项目启动时间dates for start | |||
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[1] For example: processing plants, packing plants, corrals, milking facilities, water treatment systems, food storage areas, medical and veterinary storage areas, hay preparation and silage areas, pasture areas and/or fodder banks, dairy factories, etc.比如说：咖啡加工厂，包装间，侯宰栏， 挤奶设备，处理系统，种子储藏，兽药储藏间，干草和饲料准备区。放牧区和/或饲料库，制酪厂等等。
[2] Data is provided by the farm when available or used. This information should be prepared by the client prior to the audit, to allow verification by the certification team. If unavailable, then specify Data unavailable. 数据是农场可用的有效数据。这个信息应该由客户在审计之前准备, 这样审核团队才能分析这些数据。如果没有,应说明没有数据；