Central Oregon Retailer Application

Do you currently own and operate an independently owned* convenience store in Central Oregon?*A business that is privately owned and operated without being controlled by a larger corporation, franchise, or chain. The owner(s) make key decisions about operations, finances, and policies rather than following directives from a parent company.

YESNO

Contact Information

Name of the Store

Name of the Owner of the store

Store Phone

Contact Email

What is the address of the store?

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Do you hold a valid Oregon tobacco retail license?

YESNO

When does your tobacco retail license expire?

Date

Are you currently selling tobacco products?

YESNO

What type(s) of tobacco products are you currently selling?

Cigarettes

Snus

Cigars & Cigarillos

Pipe Tobacco

Chewing Tobacco & Snuff

Roll-Your-Own (RYO) Tobacco

E-Cigarettes & Vape Products

Heated Tobacco Products (e.g., IQOS)

Hookah & Shisha

Other

Please select ALL the products your store primarily sells:

Beverages (soda, juice, bottled water, etc.)

Fresh produce (fruits, vegetables)

Frozen produce (fruits, vegetables)

Dairy products (milk, cheese, yogurt, etc.)

Frozen foods (microwave meals, ice cream, etc.)

Packaged groceries (cereal, pasta, canned goods, etc.)

Tobacco products (cigarettes, vapes, etc.)

Alcohol (beer, wine, spirits)

Lottery tickets

Hot food (pizza, hot dogs, burritos, etc.)

Coffee & fountain drinks

Health & personal care items (pain relievers, toiletries, etc.)

Household essentials (cleaning supplies, batteries, etc.)

Automotive supplies (motor oil, windshield wiper fluid, etc.)

Gasoline

Other

Using your best estimation, What percentage of your store’s current revenue comes from the sale of tobacco products? E.g. Cigarettes, cigars, smokeless tobacco, hookahs, electronic cigarettes, and pipes.

Using your best estimation, What percentage of your store’s current revenue comes from the sale of Alcohol?

Using your best estimation, What percentage of your store’s current revenue comes from the sale of Snacks & Beverages*? *Non Alcoholic Beverages (soda, juice, bottled water, etc.)

Using your best estimation, What percentage of your store’s current revenue comes from the sale of Fresh Produce?

Do you currently display tobacco and alcohol advertisements in your store?

YESNO

What role does tobacco and alcohol advertising play in your store? Please describe the visibility and placement of these advertisements.

Which grant tier are you applying for?

Tier 1: Discontinue Tobacco Retail License

Tier 2: Visibility Reduction and Removal of All Flavors

Tier 3A: Remove All Flavors

Tier 3B: Visibility Reduction

Why are you interested in participating in the Healthy Retail project? How does this align with your business goals?

How do you envision the grant funds benefiting your store and the community?

If awarded the grant, are you willing to make changes to the visibility or availability of tobacco and alcohol products in your store?

YESNO

If awarded the grant, are you willing to Introduce or expand the availability of healthy food options, such as fresh produce?

YESNO

What challenges (if any) do you anticipate in implementing these changes, and how do you plan to address them?

How will you promote these healthier changes to your customers and community?

Mandatory Add-On:
Retailers must choose one alcohol-related add-on from the following options:

Limit Alcohol Advertising: Remove alcohol posters, signage, or promotions from windows, doors, and checkout areas.

Positive Messaging Swap: Replace alcohol advertisements with messaging that promotes healthy products.

Minimize Alcohol Prominence: Relocate alcohol products away from high-traffic or eye-catching spots, such as the front of the store or checkout counters.

Choose one alcohol-related mandatory add-on from the following options:

Limit Alcohol Advertising

Positive Messaging Swap

Minimize Alcohol Prominence

You have selected 'Limit Alcohol Advertising' as your mandatory add-on. Please briefly describe your initial implementation ideas.

You have selected 'Positive Messaging Swap' as your mandatory add-on. Please briefly describe your initial implementation ideas."

You have selected 'Minimize Alcohol Prominence' as your mandatory add-on. Please briefly describe your initial implementation ideas.

Optional Program Bonus:
Retailers participating in any tier can select multiple bonus options, but the total reimbursement across all selected bonuses cannot exceed $5,000. If more bonuses are chosen, the amount available for each may be smaller to stay within the overall limit.

Healthy Product Checkout Stocking ($1,000 max)
Funding can be used for shelving, displays, and initial stocking of nutrient-dense food items at checkout, such as unsweetened beverages, fruits, nuts, and whole-grain snacks.

Healthy Marketing Practices ($2,000 max)
Supports the removal of at least 80% of tobacco and alcohol ads, replacing them with signage promoting healthy products like fruits, vegetables, and nutritious snacks. Funds cover design, printing, and installation.

Community Engagement Bonus ($2,000 max)
Covers advertising efforts such as postcards, flyers, or digital ads to promote the store’s healthy offerings. Can also fund food tasting events or coupons to encourage customer engagement.

Customer Loyalty Program ($3,000 max)
Funds the creation of a loyalty program that rewards customers for purchasing healthy products. Can be used for software, marketing materials, and incentives like discounts or free items.

Fresh Produce Display Support ($4,000 max)
Helps purchase refrigerated or attractive shelving for fresh produce, ensuring it is prominently displayed in a high-traffic area.

Healthy Grab-and-Go Options ($1,000 max)
Supports the introduction or expansion of quick, healthy snacks like pre-cut fruits, whole-grain bars, nuts, or yogurt. Funds can be used for product sourcing, packaging, and display equipment.

Youth Engagement Section ($2,000 max)
Funds the creation of a “Road Trip Snacks for Kids” section featuring nutritious, kid-friendly options like milk, fruit, and granola bars. Covers shelving, signage, and engaging elements like toys or activities.

Shelf Labeling for Healthy Choices ($500 max)
Supports the implementation of clear shelf labels highlighting nutrient-dense products, such as "Low Added-Sugar" or "High in Fiber." Funding covers the cost of labels and materials.

Item Pricing (TBD)
Provides a subsidy to lower the price of fruits and vegetables, funded by a 10% increase in soda prices. The exact subsidy amount will be tailored to the store’s pricing structure.

If any, which healthy retail Program Bonus are you interested in pursuing? (Check all that apply)

Healthy Product Checkout Stocking

Healthy Marketing Practices

Community Engagement

Customer Loyalty Program

Fresh Produce Display

Healthy Grab-and-Go Options

Youth Engagement Section

Shelf Labeling for Healthy Choices

Supplemental Item Pricing

Healthy Product Checkout Program Bonus: Please briefly describe your initial ideas for implementation, as you indicated interest.

Healthy Marketing Practices Program Bonus: Please briefly describe your initial ideas for implementation, as you indicated interest.

Community Engagement Program Bonus: Please briefly describe your initial ideas for implementation, as you indicated interest.

Customer Loyalty Program Bonus: Please briefly describe your initial ideas for implementation, as you indicated interest.

Fresh Produce Display Program Bonus: Please briefly describe your initial ideas for implementation, as you indicated interest.

Healthy Grab-and-Go Options Program Bonus: Please briefly describe your initial ideas for implementation, as you indicated interest.

Youth Engagement Section Program Bonus: Please briefly describe your initial ideas for implementation, as you indicated interest.

Shelf Labeling for Healthy Choices Program Bonus: Please briefly describe your initial ideas for implementation, as you indicated interest.

Supplemental Item Pricing Program Bonus: Please briefly describe your initial ideas for implementation, as you indicated interest.

How would your participation in this program impact your community? Please include specific examples (e.g., improved access to healthy food, reduced exposure to tobacco/alcohol products).

Do you currently engage with the local community in any way (e.g., sponsorships, partnerships, events)? If yes, please explain.

Optional: Please attach any additional information or documents that you feel demonstrate your store’s commitment to this program.e.g., photos of current store layout, community feedback, letters of support.

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Central Oregon Retailer Application