Form TM-28 USDA Farmers Market Application

OMB 0581-0229

USDA FARMERS MARKET APPLICATION

Upon completion, mail or fax application to:

USDA/AMS/TM/MSD

1400 Independence Avenue, S.W., Rm. 4004-South

Washington, D.C. 20250

(202) 690-0031 – fax

For more information call:

1-202-720-8317

Other Farmers and/or

Name:____________________________ Employees Participating in Mkt:_________________

_____________________________________________________________________________

Farm/Business Name:___________________________________________________________

Farm/Business Address*:_________________________________________________________

_______________________________________________________ ___________________

(city) (state) (zip) (county)

*Please attach a map and directions to this location.

Mailing Address (if different):______________________________________________________

(city) (state) (zip)

Home Phone:___________________________ Business Phone:_________________________

Mobile/Beeper:__________________________ E-mail Address:_________________________

Farm Acreage: Total:_____________ Type of Vendor*:_______________________________

*Please indicate specific types of products sold on page 2 of this application.

Certified Organic: _______yes _______no

Do you have farm liability insurance which covers incidents that may occur off your farm premises? _______yes _______no

Do you have product liability insurance? _________yes _______no

If you answered yes to any of the above liability insurance questions, please provide the following information: ______________________________ ________________________________

Name of Policy Holder Policy Number

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 0581-0229. The time required to complete this information collection is estimated to average 7 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. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Product	Month(s) Available	Product	Month(s) Available
Apples		Lettuce
Apricots		Okra
Blackberries		Onions
Blueberries		Peas
Cantaloupes		Peppers
Cherries		Potatoes
Grapes		Radishes
Nectarines		Squash
Peaches		Tomatoes
Pears		Turnip Roots
Plums		Zucchini
Raspberries		Pumpkins
Strawberries		Jam/Jellies
Watermelons		Honey
Asparagus		Baked Goods
Beans		Apple Cider
Beets		Cheese
Broccoli		Herbs
Brussels Sprouts		Flowers
Cabbage		Plants
Carrots		Fish
Corn		Meat
Cucumbers		Poultry
Eggplant		Other:
Greens
Leeks

Certification of Application

I certify that the information in this application is, to the best of my knowledge, true and accurate and that I am a legal owner and/or representative of the above-named farm/business.

_____________________________________ __________________________

Signature of Farmer/Vendor Date

2

TM-28