Produce Perks Mobile Market Application

Thank you for your interest in Produce Perks.

This form is for mobile markets.
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.

Please do not complete this form if your market already offers Produce Perks.

If you are a farmers' market, please complete this application.
If you are a farm stand or a farm offering direct sales or a CSA, please complete this application.

If you are a grocery store, or other brick and mortar, owner/operator, please review the information for Grocery Stores & Retail Sites and complete the Interest Form, 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/

Produce Perks Mobile Market Application

Market Name

Mobile Market Information

Primary Address

Street Address

City

State

Please use the two letter state abbreviation.

Zip Code

Zip Code +4

Need help finding your market's zip code extension? Visit https://tools.usps.com/zip-code-lookup.htm?byaddress.

Need help finding your market's Zip Code +4?
Visit https://tools.usps.com/zip-code-lookup.htm?byaddress.

County

Schedule Information

Market Frequency

Please detail mobile market schedule information. If possible, please provide a link to where schedule updates can be found.

If your market hours change seasonally, please indicate that information here. Ex. May-Oct, 12pm-6pm; Nov-Apr, 2pm-6pm.

When does your location open & close for the year?

If your location is open year-round, enter January 1 as the start date and December 31 as the end date.

If your market is a winter market that opens in the fall and ends in the spring, your start date should be the date of the first market in 2024 and your end date should be the last market of 2024.
Please add notes to the Additional Information box above to clarify.

The start date should be no sooner than 01/01/2024 and the end date should be no later than 12/31/2024.

Season Start Date

Season End Date

Mailing Address

This is the address where we should send postal mail.

Mailing Address

Mailing City

Mailing State

Please use the two letter state abbreviation.

Mailing Zip

Shipping Address

This is the address where we should ship program materials.
This cannot be a PO Box.
It should be an address where someone is generally available to sign for a package, or where a signature can be coordinated if needed.

Shipping Address

Shipping City

Shipping State

Please use the two letter state abbreviation.

Shipping Zip

Public Information

Public Phone

Public Email

Website

Facebook

Instagram

Twitter

Page 3

SNAP Information

SNAP Authorized

FNS Number

This is a 7-digit number printed on the SNAP permit sent to you when you became authorized to participate in SNAP. Please include any leading zeros.

Date of SNAP Authorization

Do you use tokens or paper scrip to represent SNAP dollars at your market?

What is the name of the Owner/Operator listed on the SNAP authorization?

Please refer to your FNS Authorization certificate. This is always an individual - not an organization.

FNS Certificate

Who is your SNAP/EBT service provider/payment processor?

If your location accepted SNAP during the previous calendar year, what were SNAP sales?

Market Operations

YEAR mobile market began operating

How many paid staff does the market have?

How many volunteers does the market have?

Which payment methods does the market accept? Select all that apply.

WIC FMNP

Senior FMNP

How many total vendors are participating in the market this year?

How many of these vendors sell SNAP eligible products?

How many of these vendors sell Ohio-grown fruits and vegetables?

Does your market allow vendors to sell non-Ohio grown produce?

Do your market offer any of these convenience services? Select all that apply.

Online Ordering	Delivery
Curbside Pick-Up	None of the above

Does your market currently offer, or has the location previously offered, an incentive program?

Please provide a brief overview of the incentive program. What purchases were incentivized? What customers could participate? What was the incentive?

Page 4

Ownership Information

Who is the fiscally responsible organization/company/individual?

The name of the entity or person on your W9.

What type of entity is the fiscally responsible organization/company/individual?

If Other, please describe.

Address as it appears on W9

W9 Street Address

W9 City

W9 State

Please use the two letter state abbreviation.

W9 Zip Code

Contacts

Please complete the information for four key contacts. If one individual fills multiple roles, please enter their information in each applicable area.

Primary Program Contact

The Primary Program Contact is the person who will be responsible for program operations if your market is accepted to participate in Produce Perks.

First Name

Last Name

Title

Phone Number

Email Address

Authorized Official

The Authorized Official is the person who is legally authorized to sign contracts if your market is accepted to participate in Produce Perks.

First Name

Last Name

Title

Phone Number

Email Address

Financial Contact

The Financial Contact is the person who will be responsible for accounting and invoicing if your market is accepted to participate in Produce Perks.

First Name

Last Name

Title

Phone Number

Email Address

Produce Perks Farmers' Market Application

How did you hear about the program?

Why is the market interested in offering the program?

Is there any additional information that you would like to share about the market?