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

(Office Use Only)

FMNP Vendor #__________

Information must be provided below for the Roadside Stand in order to participate in the Farmers' Market Nutrition Program. Information provided will be made available to benefits card recipients in order for them to know which Roadside Stands are approved to receive benefits cards, stand location and schedule of operation. Information provided will also be used in promoting the stand 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 Roadside Stand and Farmer:*

2. Stand Location (Address/Directions):*

Schedule of Operation (Months Open, Days of Week and Hours of Operation):*

3. Mailing Address:*

Street Address or P.O. Box

Street Address or P.O. Box Line 2

CityState

Zip Code

4. Phone Number (If desired to be published in the Directory):

Please enter a valid phone number.

5. 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 phone number.

Email*

example@example.com

Website:

6. Primary Products Offered for Benefits Cards (To be Published in Directory):

IN WITNESS WHEREOF, the following parties agree to accept the "Roadside Stand 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 stand and as agreed upon in the Farmers’ Market Nutrition Program Agreement and Farmer Handbook.

Farmer Signature*

Date*

Date

___________________________________________________________

LDAF Representative or Designee Signature/Date

___________________________________________________________

LDAF FMNP Director Signature/Date

PLEASE NOTE THAT YOUR FARMER VENDOR DISPLAY SIGN MUST BE POSTED DURING THE HOURS YOUR STAND IS OPEN TO RECEIVE FMNP BENEFITS CARDS. TYPICALLY, YOUR SIGN SHOULD BE POSTED JUNE 1-NOVEMBER 30.

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.