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Contact Details:
* First Name : 
* Last Name : 
* Address 1 : 
   Address 2 : 
* City : 
* State : 
* Zip : 
* Phone : 
Email Address : 
 
 
 
* Age:
   
 
 
 
* Occupation:
   
 
 
 
* If farmer, Are you a full time farmer?
 
Yes
 
No
 
 
 
If No, How many months in a year you dedicate for farming?
   
 
 
 
If farmer, What is the size of land owned by you?
   
 
 
 
* Nearest big town from your city village?
   
 
 
 
* Distance from that big town from your city/village?
   
 
 
 
What type of agricultural inputs you require to buy in a year?(e.g Agri-Inputs: seeds, pesticides, insecticides, yield enhancers, Plant nutrients, bio-stimulants etc.)
   
 
 
 
How often you require to these agri-inputs?