producer Interest form

First Name

Last Name

Business Name

Street Address

City

State

Zip Code

Email Address

Website (if applicable)

Are you a member of a collaborative, partnership, hub or other group? Are you a member of a collaborative, partnership, hub or other group? Yes No

List your primary commodities

List other commodities you can produce

Do you have a truck(s) to make deliveries? Do you have a truck(s) to make deliveries? Yes No

In which district(s) are you able to make deliveries?

Would you like to refer other producers? Would you like to refer other producers? Yes No

Please list producer name(s) and contact information