Department of Agriculture MECHANIZATION PROGRAM Recipients Validation Form Date of Validation: L GEOGRAPICAL INFORMATION 41, Region = 2. Province 3. CityMunicipalty nen 4, Barangay ee 5. Vilage/Sitio ———— I. ORGANIZATION 1. Name of Organization 2. Mailing Address 3, Telephone Number 4, Contact Person Position Contact Ml. REQUIREMENT FROM RECIPIENTS: 1, Farmers Association (F.A) SEC/CDA/DOLE Registration 2. Registration list of bona-fide members and area of farms,any 3. FA. Board Resolution 4, MAOIPAOICAO Certification endorsement REMARKS2of 2 5. Pro-forma Project Proposal 6. Location of official garage 7. Qwner of the garage Tobe validated: © Presence of F.A. office © Location ‘© Total Production Area of FAs members © Total Number of membership © Activities of FAs © Other related information: Other information ‘* Name and contact Number of the FA Representative: * LGU representative and contact number: Validated by: Technical Staff DA RFU Staff LGU Representative Noted by: Informant:EndorsementCertification from the MAO/PAO/ICAO This is to endorse the — of , with address at for the application for mechanization facility assistance from DR-RFU — - This is also to certify that the said FA has: 1. been/is currently involved in palay production and other related undertakings in the rice industry; 2. the capability to operate the mechanization facility; and 3. a minimum of hectares of (non-irrigated and hectares (_ )irrigated rice land so that the operation of the facility will be fully optimized. This endorsement and certification is being issued this day of , 2017, at Endorsed and Certified by: Name/Signature and Position Date: Contact Number:7 ANNEX A. Machinery and Equipment Utilization Proposal Date of Request: ABSTRACT OF REQUEST : Machinery / Equipment Requested: Capacity of Machinery/Equipment: Proposed No. of hrs/day of operation: No, of days operated/year: PROFILE. OF REQUESTING PARTY Name of the Proponent (Pas/POs}:_ Address: Contact Person & Contact Number: ‘No. of Members: _ Number of Intended Beneficiary Members of Machinery/Equipment: Registration; O SECC CDA O DOLE 5 others___Year registered: PROFILE OF SERVICE AREA Location and Coordinates: [Crops Planted Basing T Potential Cropping ee an (““areaha (“Wield MT/pr_|_Areaha | Viel MT/yr | Peryear I { L OTHER INFORMATION With available machinery shed: £) Yes 7 Né, Remarks: Land Ownership (Machinery Shed): C) Owned C] Donated C) Lease O) Others: With trained operators: (1 Yes No, Remarks: Other Avaifable Agricultural Machinery and Equipment Source of 0 & M Funds: 0) Service fee 1 Organizational fund, © Others: Business operation(s): Prepared by: Validated by: (Requesting Party) (RFO Representative)