Contact Name: ________________________________________________
"Business" Name: _____________________________________________
E-Mail Address: _______________________________________________
Phone: ________________________________ Fax: __________________________________
Street Address 1: _______________________________________________________________
Street Address 2: _______________________________________Apt. # __________________
City: ___________________________ State: ______________ Zip Code: _________________
Tax ID # _____________________________________________________________________

GA Dept. of Agriculture Food Sales Establishment License Number (if applicable):
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Please describe the Georgia grown, Georgia produce or handmade products that you would like to sell.
If you are selling produce, please tell us a little about your farm/garden:

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Dates of participation at PS Farmer's Market: ________________________________________
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