Contact Person *

First Name

Last Name

Farm or Business Name

First Name

Last Name

Phone *

(###)

###

####

Address - Farm/Business Location *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Liability insurance is required to sell food products through the online market. Do you have liability insurance that covers selling agriculture products? *

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? *

Yes

No

n/a

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 Application Submission *

MM

DD

YYYY