I. Membership Type

Market Membership and BFBL Application Form For office use only: Paid Amount: ______Check Number:

Please mail form along with a check made out to “WVFMA” to: Project Coordinator West Virginia Farmers Market Association 4700 MacCorkle Avenue SE Suite 101 Date: ____ / _____ /_____ Charleston, WV 25304 Phone: 304-542-3331 [email protected]

I. Membership Type: ** Market must be located within the West Virginia foodshed and be a producer-only market. Certain restrictions apply (see Buy WVFMA Membership Check All Buy Fresh, Buy Local Membership Check All Fresh Buy Local WV guidelines at Type Cost that Apply Type** (see instructions on right) Cost that Apply http://wvfarmers.org/buylocalwv/ or contact WVFMA Farmers Market via email [email protected]) Farmers Market WVFMA Membership + BFBL Membership Member $ 50.00 (additional to the $50 for WVFMA $ 15.00 NOTE: The West Virginia foodshed is Friend of the WVFMA $ 25.00 Farmers BFBL membership only $ 35.00 defined as within the WV border or within 50 miles of the WV border. Associate of the WVFMA $ 35.00 Restaurants BFBL membership $ 90.00 Sub-Total A= Sub-Total B= _____ If you selected a BFBL membership, Total Owed (Sub-Total A + Sub-Total B)= check here to indicate that you have read and understand the requirements of the BFBL program at II. Market Information:

The relevant information provided below will be used to create your web page in the members’ section of the WVFMA website: www.wvfarmers.org

Person contact name: ______

Market Name: ______Market Website(s): ______

Phone: ______Email: ______County: ______

Mailing Address: ______City ______State ______Zip ______

III. Characteristics of Your Market

A. Physical Address of Market Location(s): C. Age of Market:

1. ______Year market established: ______2. ______3. ______4. ______

B. Market Season: D. Does your market accept the following?

Avg Date Market Opens: ______Credit Cards: ____ Debit Cards: ____ Checks: ______Avg Date Market Ends: ______Hours of Operation: ______WIC: _____ SFMNP: _____ SNAP EBT: ______Women, Infants & Children Senior Farmers Market Nutrition Program Electronic Benefit Transfer of Supplemental Nutrition Assistance Program IV. Market Data

A. Estimated total sales for each market for latest season: $ ______

B. Estimated number of customers at your market each week: ______Please mail form along with a check made out to WVFMA to: Project Coordinator WVFMA Membership Form West Virginia Farmers Market Association 4700 MacCorkle Avenue SE Suite 101 Charleston, WV 25304 C. Estimated number of vendors present at your market on an average day: ______

Please mail form along with a check made out to WVFMA to: Project Coordinator WVFMA Membership Form West Virginia Farmers Market Association 4700 MacCorkle Avenue SE Suite 101 Charleston, WV 25304 CTF SCHOLARSHIP OPPORTUNITY

One of the exciting developments with the WVFMA this year is a partnership, recently formed with Change the Future WV, a statewide effort funded by a Community Transformation Grant. Because one of their organization’s objectives is to increase access to fresh, local food, they are offering support to WV farmers markets by funding WVFMA membership fees for 2013 for any farmers market in the state, as well as the membership fees to the Buy Fresh, Buy Local WV program for all markets that qualify. Your market's responsibilities under the agreement would be to cooperate with the local representatives of Change the Future WV (CTFWV) when contacted to determine any cooperative efforts that might benefit your organization, local producers and the goals of CTFWV and open avenues for increased availability and marketing of local fresh foods.

If you have any questions in the meantime, please do not hesitate to contact our Project Coordinator, Kelly Crane, at (304) 542-3331 or [email protected]. We look forward to working with each of you in the coming market season.

____ My organization would like to accept a scholarship from the Change the Future program to cover the fees for the attached WVFMA membership application. Please contact us with more information about partnership and funding opportunities.

Name: ______

Signature: ______

Amount of Requested Scholarship: $______

[If you have selected this option, you do not need to enclose a check. Your fees will be paid through the Change the Future program]

____ My organization would prefer to fund the fees ourselves for the attached WVFMA membership application.

We have enclosed a check for the following amount: $______

Please mail form along with a check made out to WVFMA to: Project Coordinator WVFMA Membership Form West Virginia Farmers Market Association 4700 MacCorkle Avenue SE Suite 101 Charleston, WV 25304