Name of Contact Person *

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone *

(###)

###

####

Other Phone

(###)

###

####

Best method of contact *

Check all that are relevant.

Email

Text

Phone

Liability insurance is required to sell food products through the online market. Do you have liability insurance that covers selling agriculture products? If yes, please provide a copy of proof of insurance. *

Yes

No

A meat handler’s license is required to store and/or sell meat through the online market. Do you have a meat handler’s license? If yes, please provide a copy. *

Yes

No

Do you have a certificate of registration from the NC Department of Revenue? *

Yes

No

Piedmont Fresh would like to track the economic impact of the food hub. Will you grant Davidson County Local Food Network permission to track your product inventory? *

Yes

No

Date of Contract *

MM

DD

YYYY