Free FMNP Application for Farmstands, DPH 4819 - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 4819 (Rev. 01/08)

STATE OF WISCONSIN Bureau of Community Health Promotion

FARMERS' MARKET NUTRITION PROGRAM (FMNP) APPLICATION FOR FARMSTANDS
INSTRUCTIONS · Farmstand operators who wish to accept WIC and Senior FMNP checks at a farmstand site must complete this form. · If the farmstand has been approved in the past, some of the previously provided information is preprinted on the form. If any preprinted information is incorrect, please correct it. Complete any areas that do not have preprinted information. · All requested information must be provided. The review process will be delayed if all of the information is not provided. · If additional space is needed to provide the requested information, an additional sheet of paper may be attached. · Submit the completed form to: Division of Public Health, FMNP, PO Box 2659, Madison, Wisconsin 53701-2659. · The applicant will be notified if WIC and Senior FMNP checks may be accepted at the farmstand site. This institution is an equal opportunity provider.
SECTION 1 ­ Vendor Information Name of Applicant Street Address of Applicant

FOR OFFICE USE County:________________________________________ Vendor ID:________________________________________ Approval Date:________________________________________

City, State, Zip Code

Telephone Number of Applicant (Include Area Code)

Email Address of Applicant (optional) SECTION 2 - Farmstand Information Name of Farmstand/Business

May we share your contact information with organizations that promote farmstands/markets? Yes No Location Information (For example, Capitol Square Park)

Street Address of Farmstand Type of Produce Sold

City, State (Must be WI)

County

The FMNP requires a trained seller to be present. Will a FMNP trained seller be present during open hours? Yes No

What is the main product sold at the site? Wisconsin-grown fruits and vegetables Plants Crafts Other, specify: ____________________________

Is produce not grown in Wisconsin available at the site? 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 farmstand to accept FMNP checks? Yes No

Does your farmstand accept Wisconsin QUEST Card purchases? "QUEST Card" is the plastic card used for FoodShare/Food Stamp Program purchases. Yes No

Dates open when FMNP produce is available. (Example: "August 1 through October 31". Provide specific dates.)

Farmstand Hours (Example: 1:00 PM ­ 5:00 PM)
Sunday Wednesday Saturday Monday Thursday Tuesday Friday