LFPA New Farmer Intake- Multi Language

LFPA New Farmer Intake

Name of Farm*

Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code

Is physical address of farm the same as billing address?*

YesNo

Address of Farm (If different from billing address)*

Street Address

Street Address Line 2

CityState

Zip Code

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Are You a BIPOC (Black Indigenous, and People of Color) producer?*

YESNO

Do you identify as a socially disadvantaged producer? (USDA definition is below.)*

YESNO

“A socially disadvantaged group is one whose members have been subject to discrimination on the basis of race, color, national origin, age, disability, and, where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or a part of an individual's income is derived from any public assistance program. “ Further, “Socially disadvantaged individuals are those who have been subjected to racial or ethnic prejudice or cultural bias within American society because of their identities as members of groups and without regard to their individual qualities. The social disadvantage must stem from circumstances beyond their control.”

What Connecticut grown or produced products do you offer?

If you grow vegetables, what types?

Estimated annual quantities or pounds for each item:

Do you have the ability to deliver these products to a local program or Connecticut Foodshare in Wallingford?

YESNO

Additional questions or comments: