2025 Louisiana Farmers' Market Nutrition Program Farmers' Market Application and Information Form

(Office Use Only)

FMNP Market #__________

The information below must be provided for the Farmers’ Market to participate in the Farmers’ Market Nutrition Program. Information provided will determine eligibility to participate in the program and will also be used in promoting the market by the Louisiana Department of Agriculture & Forestry as one supporting the Farmers’ Market Nutrition Program. The Farmers’ Market Nutrition Program (FMNP) refers throughout the document to compliance with both the Senior Farmers’ Market Nutrition Program (Senior FMNP) and WIC Farmers’ Market Nutrition Program (WIC FMNP) unless specifically stipulated as Senior FMNP or WIC FMNP.

1. Name of Farmers’ Market:*

2. Market Location/Schedule of Operation (Month Open/Days of Week/Hours of Operation):

3. Mailing Address*

Street Address or P.O. Box

Street Address or P.O. Box Line 2

CityState

Zip Code

4. Person to Represent the Market:*

First NameLast Name

Mailing Address (If different from above):

Street Address or P.O. Box

Street Address or P.O. Box Line 2

CityState

Zip Code

Phone Number:*

Please enter a valid phone number.

Fax Number:

Please enter a valid fax number.

Email:*

example@example.com

Website:

5. Approximate Number of Farmers Who Sell at the Market During an Average Week:*

Approximate Number of Other Vendors Who Sell at the Market During an Average Week:*

6. Do you currently provide nutrition education at your market site(s)?*

If so, who is providing the nutrition education, how often and in what manner?

7. Does your market have an incentive program for Farmers’ Market Nutrition Program benefits card shoppers such as “Market Match” that gives them additional funds to use at the market if they use all of their benefits?*

If so, please explain how this program works.

8. Does your market have a current list of rules and regulations governing participation and conduct in the market?*

If so, please attach a current list of your market rules and regulations.

9. Upon signature of the Market Representative, you agree to abide by the following conditions to receive authorization by the Louisiana Department of Agriculture & Forestry to participate in the Farmers’ Market Nutrition Program:

a. Cooperate with the Louisiana Department of Agriculture & Forestry, local agencies and local farmers in promoting the Farmers’ Market Nutrition Program as an approved farmers’ market program in your market.

b. Recommend to the department those farmers who sell at the market who are eligible to be certified. Likewise, do not recommend farmers or any other vendor who do not meet the eligibility standards to participate in the program.

c. Assist in monitoring the FMNP participating farmers to ensure compliance with program rules as specified in the FMNP Farmer Participation Agreement signed by participating farmers. At a minimum, monitor rules for posting Vendor Display Signs and Produce Price Signs, and make sure that farmers are extending the same courtesies to benefits card recipients as they do to other customers, including produce quality and price, and make sure participating farmers abide by the USDA nondiscrimination policy prohibiting discrimination on the bases of race, color, national origin, sex, age, disability, reprisal or retaliation for protected activities.

d. Assist benefits card recipients in identifying certified farmers and buying produce with their benefits cards, and monitor the use of benefits cards to ensure compliance with the FMNP rules.

IN WITNESS WHEREOF, the following parties agree to accept the “Farmers’ Market Application and Information Form” as correct to its content and agree to fully support and cooperate with the other party in the Louisiana Farmers’ Market Nutrition Program at this market.

Market Representative Signature*

Date*

Date

___________________________________________________________

LDAF Representative or Designee Signature/Date

___________________________________________________________

LDAF FMNP Director Signature/Date

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the State or local Agency that administers the program or contact USDA through the Telecommunications Relay Service at 711 (voice and TTY). Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Mail Stop 9410, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.

USDA is an equal opportunity provider, employer, and lender.