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c)Nn3 n,s I-ozz~ <br />lJ~®A FARf~IER~ il~ARKE-f APPLICAI-ION <br />Upon completion, mail or fax application to: <br />USDAIAMB/TM/MSB <br />1400 Independence Avenue, S.W., Rm. 2646-South <br />Washington, D.C. 20250 <br />(202) 690-0031 -fax <br />For more information call: <br />1-800-384-8704 <br />Name: <br />FarmBusiness Na <br />Farm/Business Addressk: <br />(city) <br />(state) <br />*Please attach a map and directions to this location. <br />Mailing Address (if different): <br />Home Phone: <br />Mobile/Beeper: <br />Farm Acreage: Total: <br />Other Farmers and/or <br />Employees Participating in Mkt: <br />(city) <br />(state) (zip) <br />Business Phone: <br />E-mail Address: <br />Type of Vendor*: <br />*Please indicate specific types of products sold on page 2 of this application. <br />Certified Organic: yes no <br />Do you have farm liability insurance which covers incidents that may occur off your farm premises? <br />yes no <br />Do you have product liability insurance? yes no <br />If you answered yes to any of the above liability insurance questions, please provide the following <br />information: <br />Name of Policy Holder <br />Policy Number <br />0 <br />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 <br />information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0581-0229. The time <br />required to cornplete this information collection is estimated to average 5 minutes per response, including the time for reviewing instnrctions, searching <br />existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The U. S. Department of <br />Agriculture (USDA) prohibits discrimination in atl its programs and activities on the basis of race, color, national origin, age, disability, and where <br />applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all <br />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 <br />who require alternative means for communication oiprogram information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center <br />at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, <br />S W., Washington, D. C. 20250-94 i0, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer. <br />(zip) (county) <br />1 <br />TTivl-as <br />