Name of Farm, Company, or Organization:___

Contact Person for Project: Mr./Ms.___

Mailing Address: ___

Town/City: ___ County: ___ State: ___ Zip Code: ___

Farm Address (if different from above): ___

Town/City: ___ County: ___ State: ___ Zip Code: ___

Phone: Email address:

Social Security Number or Federal Tax ID Number: ___ FSA farm number: ___

How did you learn about this grant program? ___

Applicant Type: (choose one):□Individual

□ Association □ Non-Profit

Project Type: (choose one):

□Value-Added □Organic Agriculture

Food Systems Resiliency Appropriate and Emerging Agricultural Technologies

Agroforestry/Specialty Crops

Description of Project (attach additional sheets if needed):

Are you working with your local ANR or Horticulture extension agent? Yes ☐ No ☐ If so, please provide their name(s) here: