Form TM-28 USDA Farmers Market Application

OMB 0581-0229

USDA FARMERS MARKET APPLICATION

USDA/AMS/TM/MSD

Washington, D.C. 20250

Phone: (202) 720-8317 – Fax: (202) 690-0031

R eturning Vendor: New Vendor:

Provide names of employees

Vendor Name:____________________________ that will assist you at this Mkt:____________

_____________________________________________________________________________

Farm/Business Name:___________________________________________________________

Farm/Business Address*:_________________________________________________________

_______________________________________________________ ___________________

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

Farm Acreage: Total:_______________ USDA Certified Organic: Yes: ____No:____

(certification documents required)

Mailing Address (if different):______________________________________________________

(city) (state) (zip)

Home Phone:___________________________ Business Phone:_________________________

Mobile Phone:__________________________ E-mail Address:__________________________

Website Address:________________________________________________________________

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

Will you need electrical access to operate your business at the market? Yes:____ No:____

If you answered yes, list all items below that will require electricity for the market season:

_____________________________________________________________________________

For returning vendors, do you donate to the food bank gleaning program? Yes:____ No:____

As a new vendor participating in the market are you willing to donate to the food bank gleaning program?
Yes:____ No:____

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.

Check the general category(s) of products that you will be selling at this farmers market:

Row Crops/Vegetables Orchard/Fruit/Berries Dairy/Milk/Cheese
Eggs Frozen Meat/Poultry (USDA Inspected Only) Honey/Maple Products

Baked Goods Prepared Foods Value-Added Products

Other:_______________________________________________________________________________

Please attach a complete list of products that you will be selling at this market and the months available for each product. Be sure to include all required documentation such as inspection reports, permits, and licensing associated with your farm/business. Incomplete applications can result in a delay or denial for processing your application for market participation, regardless of your seniority at the market.

An approval by the Market Management Team will be required for your product list. You may not bring a product to sell at the Market that has not been approved by Market Management.

Do you grow, make, and/or process your own products: Yes ______ No_______

What percentage do you grow:______________ What percentage do you make or process:____________

If you purchase produce/products from other sources, please provide the farm name, contact name, address and phone number: (No Wholesaling)

___________________________________________________________________________________

____________________________________________________________________________________

The USDA Outdoor Farmers Market Season will operate from June 6 through November 21. Hours of operation are 10:00 am to 2:00 pm each Friday. Vendor must arrive no later than 9:30 a.m. and be set-up to start selling by the 10:00 a.m. start time. The USDA Winter Farmers Market starts in December. Space is limited and inquires to participate will be addressed in October.

If there are dates during the outdoor market season that you expect not to attend, please indicate them below:
____________________________________________________________________________________

Please feel free to review the Market Guidelines for additional market information. Applicants who are accepted to participate in the USDA Farmers Market will be required to read the Market Guidelines, sign and submit the “Vendor Certification Page” agreeing to accept and abide by the market terms and conditions set-forth in the Guidelines. This form will be required before a vendor can participate in the market.

For consideration to participate in this market, all completed applications must be received by April 30, 2014. Applications can be obtained on-line at www.ams.usda.gov/farmersmarket and submitted by fax at 202-690-0031, by emailing [email protected] or by mail USDA/AMS/TM/MSD Attention Velma Lakins, 1400 Independence Avenue, SW, Room 4509, Mail-Stop 0269, Washington, DC 20250-0269.

Certification of Application

By signing below, 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 and will comply with all requirements to participate.

_____________________________________ __________________________

Signature of Farmer/Vendor Date

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TM-28