Register Form Farmers / Collectors

Basic Identity

NIK

Full Name

Phone Number

Personal Data

Place of Birth

Date of Birth

Gender

Religion

Highest Education

Land Information

Home Address (Village/Neighborhood)

Subdistrict - Regency - Province

Land Map Link (Google Maps)

Land Area (Ha)

Land Address

Land Latitude (X)

Land Longitude (Y)

Family Status

Marital Status

Spouse Name

Number of Children

Mother's Name

Agricultural Data

Commodity

Land Elevation (m asl)

Land Ownership Status

Type of Coffee

Number of Coffee Trees

Shade Tree Species (Other than Coffee)

Number of Shade Trees

Monthly Coffee Harvest (Kg)

Annual Coffee Harvest (Ton)

Have you ever received agricultural assistance?

If yes, from whom did you receive it?

What type of assistance was it?

Farmer Group Name

Cooperative Name

How long have you been with the group/coop? (years)

Financial Information

Primary Income Source

Additional Income Source

Bank Name

Bank Account Number

Account Holder Name

Type of Fertilizer

Fertilizer Percentage (%)

Other Crops in the Farm

Coordinates of Other Farm Locations
Note: Format like -1.2345678,101.23456789

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Upload Documents

Farmer Photo

ID Card (KTP) Photo

Family Card (KK) Photo

Farm Photo