Apply

ROPS Rebate Intake Form

First name Last name

Home phone Alternate phone Best time to call

Do you consider yourself a Full time farmer Part time farmer Not a farmer

ROPS preference Rollbar (rigid or folding) Cab Rops w/ canopy

Installation preference Dealer install Self install
	Reasons why (check all that apply)
		Convenient Expert Liability Time	Tractor in repair Capable of doing it myself Hassle to truck Lower cost

Have you ever considered retrofitting a tractor previous to the rebate program? Yes No

Have you ever retrofitted a tractor previously? Yes No

Have you ever had a serious accident on a tractor? Yes No

After installation of ROPS on your tractor do you intend to wear your seatbelt?
	Always During dangerous work Rarely

After installation of ROPS on your tractor do you intend to have family members wear a seatbelt?
	Always During dangerous work Rarely N/A

After installation of ROPS on your tractor do you intend to have workers wear a seatbelt?
	Always During dangerous work Rarely N/A

What's the reason you decided to take advantage of the rebate program? (check all that apply)
	Safety-general	Rebate money	Sun protection
	Safety for family/workers	Hilly terrain	Had a scare, need to get it on
	Required for operation	Other

Why did you choose this tractor to retrofit? (check all that apply)
	Last one in fleet	Used on dangerous ground	Use this more
	Family member uses this tractor	Worker/neighbor uses this tractor	My only tractor
	Other

Where did you hear about the rebate program? (check all that apply)
	Friend/family	Dealer	Newspaper
	Veterinarian	Cooperative Extension	Magazine
	Farm Bureau	Mechanic	Other