FERTIGATION INTAKE FORM

FERTIGATION INTAKE FORM

Please fill out this form to the best of your ability. If you would prefer to reach out to us to better understand your needs, Call us at 1-888-234-4769 or via Email at design@ccservices.info
Your Name*

First NameLast Name
Company Name*
Company Website
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Name Of Head Grower
Head Grower Phone Number / Email
Briefly describe your needs / scope of work*
Is this your first cultivation facility?
Has the building been constructed?

YesNoOther
How long have you been in the business of cultivation?*

< 1 Year1-3 Years3-5 Years5-10 Years10+ YearsOther
What is your budget?

$25k-$50k$50k-$75k$75k-$100k$100k-$125k$125k-$200k$200k+Currently UndisclosedOther

Do you need fertigation installation services?

YesNoI'm not sure
Do you need table installation services?

YesNoI'm not sure
Is the installation for a New Build or Retro Fit?

New BuildRetro Fit
If New Build: Has the building been constructed? Or is it still in the planning phase?

Already constructedStill in the planning phaseOther
Have you secured all necessary licenses and permits?*

YesNoPending
Water Source*

CityWellNot SureOther
Have you performed an irrigation water quality test?*

YesNoPendingUnnecessary
Water Main Inlet Size (Inches)
example: 1-1/2"
Does the facility have a loading dock?

YesNoNot yet
Will there be a forklift on-site?

YesNoI'm not sure
Will there be a general contractor on-site for this project?

YesNoI'm not sure
Are there currently any plants in the facility?

YesNo
Ceiling height for each room:
How much water per day is needed per plant/room every day?
How many emitters per plant?
Growing Media Type?
Number of rooms that need irrigation
List the name and dimensions of each room (If no floor plan available)
Irrigation room dimensions (If no floor plan available)
Number of zones per row of tables / Number of zones per room
Table Brand
Tiers per Room
Table Dimensions
Would you like to incorporate environmental controls?

YesNoI'm not sure
Enter your preferred environmental controls brand
Preferred nutrient company?
How many nutrients are used?
Preferred R.O system?
Preferred Fertigation System?
Will you need a water reclamation system?

YesNoI'm not sure
Watering Cycle Frequency and Duration
Are there floor drains in the irrigation room?
Are there floor drains in all rooms that require irrigation?
Ideal Start Date

MonthDayYear
Date

Do you have any floor plans of the facility that you would like to share?

YesNoNot Yet
Upload Installation Site Plans (If applicable)

Please include the floor plans of the installation site so we can better understand your company's needs.
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How did you hear about us?*

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Additional Comments / Questions
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