| Peer Reviewer Application and Qualification Form |
| For Farmers Market and Local Food Promotion Program |
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| Complete the information below to indicate your qualifications to review FMPP/LFPP proposals. The form must include a copy of your résumé with all employment and volunteer locations. Email completed form and résumé to [email protected] and indicate in the subject line if you are applying to be an LFPP or FMPP Reviewer. For more information about the grant programs, visit http://www.ams.usda.gov/services/grants. |
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| Last Name: |
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First Name: |
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| Email: |
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| Phone: |
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Fax: |
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| Street Address: |
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| City: |
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State: |
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Zip Code: |
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| Academic Background: |
| Highest Degree in Education: |
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| Degree Area: |
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| Profession/Rank: |
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| Employer: |
| Employer Name: |
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| Department: |
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| Employer Type (mark as many as appropriate): |
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Federal Employee |
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Private Sector Employee |
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Nonprofit Employee |
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State Employee |
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Farmer/Producer/Rancher |
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Public Benefit Corp |
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Tribal Government |
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CSA Employee |
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Economic Develop. Corp |
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Local Government |
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Retired/Volunteer |
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1862 Land Grant U. |
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1890 Land Grant University |
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1994 Land Grant University |
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Public non-Land-Grant U |
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Private College/University |
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Private Research |
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USDA EPSCoR |
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Small/Mid-sized Institution |
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Hispanic Serving Institution |
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Other Minority Serving I. |
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Other (Please specify): |
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| Percent of Appointment (Academia): |
| Appointment |
Percent |
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| Research |
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| Teaching |
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| Extension/Outreach |
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| Administration |
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| Total |
0 |
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| Demographic Information (Optional): |
| Gender: |
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| Race: |
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| Ethnicity: |
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| Previous Federal Grant Application Review: |
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| Conflict(s) of Interest: |
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| Expertise (mark as many as appropriate): |
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Grant Writer |
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WIC |
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Aggregator |
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Financial/Budget |
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SFMNP |
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Distributor |
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Nutrition |
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EBT |
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Direct Marketing |
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Architecture/Engineering |
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CSA Operator |
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Agri-Tourism |
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Farmers Market |
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SNAP |
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Processor |
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Farmers Market Manager |
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Agricultural Cooperative |
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Food Banks |
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Educator/Academia |
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Roadside Stand Operator |
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Environmental |
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Technical Assistance Marketing |
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Technical Assistance Business Planning |
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Agricultural Production |
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Technical Assistance Other (please specify): |
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Other (please specify): |
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| 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- -0240. The time required to complete this information collection is estimated to average 15 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, or 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 USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer. |