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? _____

Is your gross farm income more than $1,000 and less than $250,000 per year? ___Yes ___No

Is your net household income less than $23,000 per year? ___ Yes ___ No

Have you received KADF cost share funds from your county in the past five years? ___Yes ___No

Is this a new enterprise for you? ___ Yes ___ No

Are you a beginning farmer (two years or less)? ___ Yes ___ No

Do you currently produce tobacco? ___ Yes ___ No

Have you produced tobacco in the last 10 years? ___Yes ___No

Is your operation certified? Organic Transitional Exempt Certifying Agency:_____

Is this educational training out of the state of Kentucky? ___ Yes ___ No

Are you a military veteran? ___ Yes ___ No

Workshop Title (attach event agenda): ___

Description of the requested educational training (please provide available links to the training or conference):

Training Date(s): ___

Location:___

Who will attend and receive the training? ___

Who will write and submit the post-training report?___