To:
Participating Farmers 2012 Nevada Senior Farmers’ Market Nutrition Program (SFMNP)
From: State of Nevada Food Distribution Program Office RE:
Coupon Acceptance Form
As part of the acceptance policy for Nevada’s 2012 SFMNP, we are requiring all Farmer / Vendor Participants to complete, sign and return this form to the State of Nevada Food Distribution Office, PRIOR to accepting Senior coupons.
By signing this form, you agree to accept only Senior coupons authorized by the State Office for your assigned redemption code. As authorized Farmers with Nevada’s 2012 SFMNP, all Farmers may accept the 2012 white coupons. It is a violation of Program policy to accept coupons and then solicit trade with other farmers. Violations of any Program policy will result in immediate elimination from Nevada’s Program and the termination of all claims for reimbursement through this Program. Please complete this form, make a copy for your records, and return it in the enclosed envelope. Contact the State of Nevada Food Distribution Program Office with any questions or concerns involving this document or other program details (775-684-1830 or 775-684-1837). Thank you for your participation in Nevada’s 2012 SFMNP.
Farm Name: ______________________________________________________________________ Farmer/Representative Name: _______________________________________________________ Farmer/Representative Signature: ____________________________________________________
Date Signed: _____________________
__________________________________________________________________________________________ Date Received in State Food Distribution Program Office: _____________________ Date Posted: _____________________
Initials: ______________