FARMER NETWORK

Farmer enrolment form

Complete the form below. Fields marked with * are required. Please do not submit bank details or unrelated sensitive information.

1. Applicant details

First name *

Last name *

Mobile / phone number *

WhatsApp number

Email address

South African ID number (optional)

Only provide this if required for verification. Store and access it securely.

2. Location and farm

Village / settlement *

Ward (if known)

Municipality

Province

Farm / business name *

Farm address / directions

3. Poultry capacity and experience

Coop status *

Maximum coop capacity (birds) *

Birds currently on farm

Broiler farming experience *

Reliable water access?

Electricity access?

Current sales channel

4. What support are you interested in?

Bulk feed supply

Day-old chicks

Poultry health supplies / guidance

Training and farm support

Market access / buyer connections

Additional information

I confirm that the information provided is accurate and consent to Khutshembo Chicken Farm using it to assess and contact me about this enrolment application. I understand that registration does not guarantee approval or supply. *

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