Industrial Hemp Coalition Application Industrial Hemp Coalition Application 1Step 12Step 23Step 34Step 45Step 5 All Together Now PA: Industrial Hemp Coalition ApplicationAdvocating local ownership. Building regional supply chains. Seeking justice and regeneration. Name First Last Email Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CountyChoose oneAdamsAlleghenyArmstrongBeaverBedfordBerksBlairBradfordBucksButlerCambriaCameronCarbonCentreChesterClarionClearfieldClintonColumbiaCrawfordCumberlandDauphinDelawareElkErieFayetteForestFranklinFultonGreeneHuntingdonIndianaJeffersonJuniataLackawannaLancasterLawrenceLebanonLehighLuzerneLycomingMcKeanMercerMifflinMonroeMontgomeryMontourNorthamptonNorthumberlandPerryPhiladelphiaPikePotterSchuylkillSnyderSomersetSullivanSusquehannaTiogaUnionVenangoWarrenWashingtonWayneWestmorelandWyomingYorkI don't live in PennsylvaniaMobile PhoneWere you referred by a member of the coalition? If so, whom? DemographicsWhat are your preferred pronouns? She/her He/His They/their Ze/zir What is your age group? 18 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+ What is your race? Asian Black or African American Native American or American Indian Native Hawaiian or Other Pacific Islander White Multiple Races Prefer Not to Answer What is your ethnicity? Hispanic or Latinx Not Hispanic or Latinx Relationship to HempWhat is your relationship to hemp?* Hemp-related business owner Hemp farmer Hemp advocate Hemp researcher / student / writer Other (Select the one that applies the most.) *Hemp-related Business OwnerName of your business Business physical address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Website What is your business role? Majority Owner Minority Partner/Owner Employee Do you live within 50 miles of your business? Yes No Please briefly describe your business in one or two sentences:Do you currently buy locally grown hemp? Yes No No, however I would like to Where are your customers located? Within the region near your business location Within the state Within the northeast region Nationwide Globally Online distribution Are you interested in developing more customers within your region and within our state? Yes No Hemp FarmerName of your business Business physical address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Website What is your business role? Majority Owner Minority Partner/Owner Employee Do you live within 50 miles of your business? Yes No Please briefly describe your business in one or two sentences:Do you currently buy locally growth hemp? Yes No No, however I would like to Where are your customers located? Within the region near your business location Within the state Within the northeast region Nationwide Globally Online distribution Are you interested in developing more customers within your region and within our state? Yes No Hemp AdvocateAre you affiliated with any advocacy groups or organizations? If yes, please describe below.In what ways are you advocating for hemp and/or would like to do more advocacy for the hemp industry?Hemp Researcher/Student/WriterPlease share the name of school, institution or publication: Please describe your role:Other Relationship to HempPlease describe your relationship to hemp: All Together Now PAWhat do you hope to gain from being a part of the coalition?Are you interested in teaching others in any of the following areas? Cultivation Harvesting Drying & storage Processing Extraction Co-packing / labeling Lab Testing Are you interested in learning more about any of the following areas? Cultivation Harvesting Drying & storage Processing Extraction Co-packing / labeling Lab Testing Are you interested in volunteering your time? If so, what would you like to do? Host meetings at your business, farm or organization Help to organize public events Speak at public events Teach others your skills/knowledge Help strategize and organize the coalition I am not interested in volunteering at this time. Alignment of ValuesThe Hemp Local Supply Chain Coalition seeks alignment of our members around basic values in order to work collaboratively toward creating the world we want to live in and pass on to future generations. Please provide your values and beliefs to each of the following core areas.We support the local production of our basic needs, such as food, fuel and fiber, by locally owned farms and businesses in order to build community wealth and local economic power. Are you with us? Yes No Maybe Please share your values and beliefs in regards to the above.We work to decrease our reliance on long-distant corporate supply chains in order to increase regional self-reliance and resiliency. Are you with us? Yes No Maybe Please share your values and beliefs in regards to the above.We value economic justice and work to build an inclusive economy that provides opportunity for economically marginalized communities, such as small farmers, immigrants, entrepreneurs of color, women, veterans and returning citizens, in both rural and urban communities. Are you with us? Yes No Maybe Please share your values and beliefs in regards to the above.We believe that exit strategies should be designed to maintain local independent ownership of farms and businesses as much as possible. This can be done by selling to employees, family members, other local entrepreneurs or farmers, or to a community land trust or non-profit, as opposed to selling to large out-of-state corporations. Do you agree? Strongly agree Agree Neutral Disagree Strongly disagree Please share your values and beliefs in regards to the above.We work to build a conscious economy where business decisions are not made to maximize profits and material gain, but to maximize the health and well-being of our communities and eco-systems, while making a fair profit. Are you with us? Yes No Maybe Please share your values and beliefs in regards to the above.We believe that business relationships should reflect the values of cooperation, generosity, fairness, integrity, compassion, and respect for all people, nature and other species. Do you agree? Strongly agree Agree Neutral Disagree Strongly disagree Please share your values and beliefs in regards to the above. Δ
