New Hampshire Farmers’ Market Nutrition Program (FMNP)       Dept. of Agriculture Use Only

Department of Health & Human Services                                                  Date:  _______________________

Reauthorization:  ______________

New Application:  ______________

New Vendor #:_______________

 

2006 New Vendor Application Form

Please type or print clearly!

 

1.   Farm Name, Address, Location, Owner Name:

 

Farm Name:  ______________________________________________________________________________________

 

Address:  _________________________________________________________________________________________

 

City:  _________________________________________  State:  _________  Zip:  ______________________________

 

Telephone:     days:     ________________________     nights:  _________________________

 

Billing/Payment Name (check will be made out to this name):  ______________________________________________

 

Billing/Payment Complete Mailing Address: ______________________________________________________________

 

Please note:  All new vendors must complete training before authorization.  Fill out

above information completely to ensure that you can be reached to schedule training.

 

 

2.   Below is a list of the known farmers’ markets in the state, please check off where you will be participating

 for this year.

 

___Amherst                               ___Hillsborough                         ___New Durham                        ___Sanbornton

___Barrington                            ___Jackson                                ___Newport                               ___Sandwich

___Bedford                                ___Jaffrey                                 ___North Conway                       ___Sunrise (Pittsfield)

___Bethlehem                            ___Keene                                  ___Nottingham                           ___Tilton

___Canaan                                ___Laconia                                ___Peterborough                        ___Wakefield

___Chichester                            ___Lancaster                             ___Plymouth                              ___Warner

___Claremont                            ___Lebanon                               ___Rochester                             ___Weare

___Colebrook                             ___Littleton                                Seacoast:                                  ___Wilmot

___Concord                               ___Lower Cohase                       ___Dover                                   ___Wilton

(Woodsville)                  ___Durham                               

___Cornish                                ___Manchester                          ___Exeter

___Deerfield                              ___Meredith                              ___Hampton

___Enfield                                 ___Milford                                 ___Kingston

___Farmington                           ___Nashua                                ___Portsmouth

___Hancock                               ___New Boston                          ___Stratham

___Henniker                             

 

If you know of any other markets, please list them below.

______________________________________________________________________________________

 

______________________________________________________________________________________

 

 

3.   What are your anticipated dates of operation for selling produce this year?  _________________________

 

4.   How much of the produce, that you sell at the Farmers’ Market, is grown on this farm?  __________ %

5.   Has this business or owner ever received a warning from, been fined or suspended by, or been

disqualified by the WIC, FMNP, or Food Stamp Program?     Yes ____          No  _____

 

If Yes, explain:  _______________________________________________________________________________

 

6.   Please place a check mark beside the fruits and vegetables which you plan to produce for sale this year

 and list any varieties in the space provided below.

 

___Apples                                 ___Corn                                    ___Peaches                   ___Squash:

___Asparagus                            ___Cucumbers                           ___Pears                                   Summer

___Beans                                  ___Eggplant                               ___Peas                                    Winter

___Beets                                   ___Fresh herbs                          ___Peppers                   ___Tomatoes

___Blackberries                          ___Garlic                                   ___Plums                      ___Turnip, Rutabaga

___Blueberries                           ___Greens                                 ___Potatoes                   ___Watermelon

___Broccoli                                ___Leeks                                   ___Radish

___Brussel sprouts                     ___Lettuce                                 ___Raspberries

___Cabbage                              ___Mushrooms                          ___Rhubarb

___Cantaloupe                           ___Muskmelon                           ___Spinach

___Carrots                                ___Okra                                    ___Strawberries

___Cauliflower                           ___Onions                                 ___Sugar pumpkins

___Celery                                  ___Parsnips

___Chard

 

Exclusions:

Fruits and vegetables sold for decoration or ornamentation, such as Indian corn, painted pumpkins, or gourds, are

 not eligible to be purchased with NH FMNP coupons.  Prepared foods, such as jams or jellies, relishes, baked goods,

 dried herbs, alcoholic beverages, honey, syrup or cider are also excluded.  Foods grown outside of New Hampshire

 or 25 miles from the NH/VT border are not authorized to be purchased using FMNP coupons.

 

I understand this is only a request to participate in the NH Farmers’ Market Nutrition Program and does not constitute

 a contract.  All information on this application is true.  I understand that any false information may lead to my disqualification

 and any other penalties prescribed by law:

 

 


Printed Name:

Title:

Signature:

Date:

 

Please Note: Under no circumstances will any applications be accepted after

 May 15, 2006

 

Return application to:

NHDAMF-FMNP

PO Box 2042

Concord NH 03302-2042

Questions?  Contact Lynn Gallop, NH Department of Agriculture, Markets & Food at 271-3788.

 

WIC/FMNP is an equal opportunity program.  If you believe you have been discriminated against because of race, color, national origin, age, sex, or

disability, write to the Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue SW, Washington DC 20250.