New Firm Intake Form
This information is to help us get the MOU to you quicker, as well as to ensure we contact you as efficiently as possible.
Firm Information
Name of Firm
Owners Name
*
First Name
Last Name
Street Address of Firm
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Firm FNS Number
Firm hours and days of operation:
*
How many vendors are at your firm?
Contact Information for Market Representative
Fill out the following contact information for the person that you would want the WV Food and Farm Coalition to contact if they have questions.
Name
*
First Name
Last Name
Phone Number
*
Preferred phone number for contacting a market representative
Email
*
Preferred email for contacting a market representative
What is your preferred method for contacting you?
*
Email
Phone Call
Other
Do you have any questions for us that we can answer?
Submit
Should be Empty: