Free None - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Division of Public Health DPH 40053 (Rev. 11/03)

STATE OF WISCONSIN Bureau of Family and Community Health

FARMERS' MARKET NUTRITION PROGRAM (FMNP) VERIFICATION OF PARTICIPATION IN FARMER TRAINING
Participation in the Farmers' Market Nutrition Program is voluntary. Completion of this form meets the requirements of Federal Reg. 248.10a(4) which states that a face-to-face training is required for farmers to participate in FMNP. Only the farmers who did not participate the previous year should complete this form.
Date of Training Name of Trainer Farmer Name Street Address Location of Training (county/market) Agency Name (of Trainer) City State Zip Code Telephone/Area Code

I verify that farmers listed here have been trained for FMNP participation. SIGNATURE ­ FMNP Trainer

Date Signed