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: