FNS 792 Golden Grocer Award Nomination Form

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Golden Grocer Award
Nomination Form
The Golden Grocer Award Program honors retailers that provide
exemplary customer service to Supplemental Nutrition Assistance Program
(SNAP) participants and potentially eligible low-income customers.
Selection Criteria:
To be selected as a Golden Grocer, a retailer must be authorized by the USDA Food and Nutrition Service
to participate in SNAP and provide one or more of the following services (check all that apply):
Provide a list of local social service offices to customers who want to apply for SNAP
Place pre-screening kiosks in the store or make space available for staff from other
organizations to conduct screening and application assistance
Work with local social services offices and/or community partners to promote the SNAP
Provide SNAP information to customers (e.g. on receipts, grocery bags, or through the public address
system)
Highlight the benefits of the SNAP with respect to purchasing healthy food
Present and display nutrition education items throughout the store or at sponsors events which
promote healthy lifestyles
Participate in a State’s SNAP Outreach Plan
Other criteria
Type of Firm (check one):
Local Store Affiliated with a Parent Company
Independent Grocer
Farmers’ Market
Other
Nominee:

Submitter:

Name of Organization:
Address:
City:
Name of contact person:
Phone:

State:

Zip Code:

Email address:

Name:
Relation to nominee:
Phone:

Email address:

Submit on-line at http://www.fns.usda.gov/snap/outreach/default.htm or attach a short, typed statement on why
this firm should receive the Golden Grocer Award, for example, describe how they excelled at the criteria above.
Entries may be submitted any time throughout the year and awards made on an ongoing basis.
Send to:
Email to:

Golden Grocer/Hunger Champions Committee, c/o USDA, Food and Nutrition Service,
3101 Park Center Drive, Room 1441, Alexandria, VA 22302, or
[email protected]

OMB BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to
respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0524.
The time required to complete this information collection is estimated to average 45 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments
concerning the accuracy of time estimates or suggestions for improving this form, please contact: U.S. Department of Agriculture, Food and Nutrition Service,
Office of Research and Analysis, Room 1012, Alexandria, VA 22302.

Form FNS-792 (07-09) Previous Editions are Obsolete

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