Produce Perks Retail Interest Form
Thank you for your interest in Produce Perks.
This Interest Form is for grocery store, or other brick and mortar, owners and operators.
All information provided will be kept confidential.
A member of the Produce Perks team will follow-up with you within 30 days with additional questions and next steps.
If you are a farmers' market, mobile market, or farm, please complete the Farm Direct application, found
here
.
If you are a customer, please use the Market Locater Tool to find the closest market to you that offers the Produce Perks match:
https://producerperks.org/locations/
Questions with a * are required; please complete the rest of the questions to the best of your ability and Produce Perks will follow up for additional information.
Location Name
Location Address
Street Address
City
State
Zip
Zip +4
Need help finding your store's zip code extension? Visit https://tools.usps.com/zip-code-lookup.htm?byaddress.
County
Public Contact Information
Public Phone Number
If a customer were to call your location for more information, what number would you like them to call?
x
Public Email Address
If a customer were to email your location for more information, what number would you like them to call?
x
Website
Facebook
Instagram
Twitter
Application Contact
First Name
Last Name
Title
Email
Phone Number
Is this person the Owner/Manager of the location?
Please select...
Yes
No
The Owner/Manager is the person who will be responsible for signing contracts if your location is accepted to participate in Produce Perks.
Owner/Manager
First Name
Last Name
Title
Email
Phone Number
Ownership Information
Who is the fiscally responsible organization/company/individual?
The name of the entity on your W9.
What is the store's ownership structure?
Please select...
501(c)(3)
501(c)(6)
C Corporation
S Corporation
Cooperative
Cooperative Association
Individual/Sole Proprietor
LLC
LLC - C
LLC - P
LLC - S
Unincorporated Association
Other - please explain below
If Other, please describe the ownership structure.
How many stores are owned by the owner of the applying store?
Is the store owner an Ohio resident and/or is the responsible entity Ohio-based?
Please select...
Yes
No
Which of the following best describes the store owner(s)?
Please select...
Asian or Pacific Islander
Black or African American
Hispanic or Latino
Native American or Alaskan Native
White or Caucasian
Multiracial or Biracial
A race/ethnicity not listed here
I prefer not to answer
Please select all that apply.
Details & Operations
Which of the following best describes the store?
Please select...
Grocery Store, full service (more than 2,000 items)
Grocery Store, limited assortment (less than 2,000 items)
Ethnic Grocery
Co-Op Grocery Store
Corner/Convenience Store
Other
If Other, please describe your store.
What point-of-sale system does the store use?
Is the store authorized to accept SNAP?
Please select...
Yes
No
Does the store sell Ohio-grown produce?
Please select...
Yes
No
Approximately what percentage of the store's produce offerings is Ohio-grown?
Please select...
100% Ohio-Grown
66% or more Ohio-Grown
Between 33% and 66% Ohio-Grown
Less than 33% Ohio-Grown
How did you hear about the program?
Why is the store interested in offering the program?
Is there any additional information that you would like to share about the store?
Contact Information