Free FMNP Application for Farmers' Market Managers, DPH 4800 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 4800 (Rev. 01/08)

STATE OF WISCONSIN Bureau of Community Health Promotion

FARMERS' MARKET NUTRITION PROGRAM (FMNP) APPLICATION FOR FARMERS' MARKET MANAGERS
This form must be completed in order to participate in the WIC and Senior FMNP. If a separate sheet of paper is needed, please attach it to this form. Submit the information to: Division of Public Health, FMNP, 1 West Wilson Street, PO Box 2659, Madison, Wisconsin 53701-2659. If your market has been approved by the FMNP in the past, we have preprinted some of the information previously provided. Make any corrections to the preprinted information in the same space or on the reverse side. Fill in responses where there is no preprinted response. Please be sure all information is complete to ensure quick processing of this application.
SECTION 1 ­ Market Location and Information Name of Market
FOR OFFICE USE

Street Address of Market Location information (i.e., next to city park, bank parking lot)

City

County

County:________________________________________ Approval Date:________________________________________

SECTION 2 - Market Manager Information Name of Market Manager City E-mail Address of Market Manager State

Street Address of Market Manager Zip Code Area Code/Telephone Number

May we share your contact information with organizations that promote Yes No farmers' markets?

SECTION 3 ­ Market Details Specify the days and hours your market will be open (i.e., Saturdays, 7 a.m. to 5 p.m.)

Specify dates when locally-grown fruits and vegetables are available, and when at least three produce farmers will be present at the market (i.e., June 15 ­ October 31) Provide an estimate of the number of farmers participating in your market each month, beginning with June and ending with October (i.e., July-20 farmers, etc.) What is the main product sold at the farmers' market? Wisconsin-grown fruits and vegetables Plants Crafts Other, specify: ______________________________________________ June July August September October

Does your market allow selling of produce grown outside of Wisconsin? Yes No

Since the FMNP primarily allows Wisconsin-grown produce to be purchased with FMNP checks, will there be enough produce available to justify approving your market to accept FMNP checks? Yes No Does your market accept Wisconsin QUEST Card purchases? "QUEST Card" is the plastic card used for FoodShare/Food Stamp Program purchases. Yes No

Specify dates, times and locations of temporary market site relocations and/or additional dates due to festivals, construction, etc.

Does your market have an annual meeting? Yes No

If yes, can FMNP be present to train farmers on FMNP rules? Yes No

If yes, please list the annual meeting date, time and location.

Include a copy of your market rules and a map of your market. If your market was approved last season, and your map and rules have not changed since the previous year, you do not need to send the map and rules. This institution is an equal opportunity provider.