Concern Form regarding Beekeeper(s) and/or Honey Bees

TO BE SUBMITTED TO: THE STATE OF NEW JERSEY DEPARTMENT OF AGRICULTURE, OFFICE OF THE SECRETARY.

FORM CREATED BY AND TO BE SUBMITTED BY: NEW JERSEY BEEKEEPERS ASSOCIATION (NJBA), A NEW JERSEY 501(c)(5)

Please be advised that the Submitter’s information is mandatory. If information is blank, there is a possibility of non-submission.

Concern Reported By:

First Name

Last Name

Street Address (No PO Boxes)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Township & County:

Home Telephone #:

(###)

###

####

Cellphone #:

(###)

###

####

Email Address:

* Note: By providing your e-mail address, you agree to receive communications from this office by email.

Concern Reported Against:

First Name

Last Name

Street Address (No PO Boxes)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Township & County:

Telephone #, if known:

(###)

###

####

Description of property (color and style of house, outbuildings, helpful identifiers):

Describe the facts of your concern in the order in which they happened.

At minimum, please include: (1) Date(s) of incidents; (2) Date(s) of your conversations with your neighbor, including substance of conversations; (3) Actions, if any, resulting from your conversations with your neighbor; and (4) Number of colonies (how many hives):

Please Confirm you have read this Disclaimer

DISCLAIMER: THIS FORM HAS BEEN CREATED BY THE NJBA IN AN EFFORT TO ASSIST NEW JERSEY BEEKEEPERS TO MAINTAIN BEST BEEKEEPING PRACTICES WITH RESPECT TO BEEKEEPING IN THEIR COMMUNITY, AS WELL AS TO INFORM AND EDUCATE NEIGHBORS OF BEEKEEPERS AS TO THE ALLOWABLE PRACTICES AND GUIDELINES OF THEIR NEIGHBORING BEEKEEPERS IN ACCORDANCE WITH APPLICABLE NEW JERSEY LAW. IT IS THE INTENT OF NJBA THAT THIS FORM SIMPLY BE USED AS A MEANS OF FACILITATING ANY BEEKEEPER-NEIGHBOR PROBLEMS THAT MIGHT ARISE. NJBA IS IN NO WAY ACTING AS AN AGENT OR AFFILIATE OF AND IS IN NO WAY EMPOWERED OR AUTHORIZED BY THE STATE OF NEW JERSEY DEPARTMENT OF AGRICULTURE TO BE ACTIVELY INVOLVED IN ANY LEGAL ENFORCEMENT OF ANY BEEKEEPER MISCONDUCT THAT MIGHT ARISE AS A RESULT OF FILING THIS COMPLAINT.

Please Certify by typing your name in the box below:

I certify that the foregoing statements made by me are accurate and true. I am aware that if any of the foregoing statements made by me are willfully false, I may be subject to legal punishment. I hereby authorize the New Jersey Beekeepers Association (NJBA) [secretary@njbeekeepers.org] to send this CONCERN FORM to the STATE OF NEW JERSEY DEPARTMENT OF AGRICULTURE, OFFICE OF THE SECRETARY, and interested parties, and to use the information in any way that is necessary.