Do You Eat?

If you eat, and I think most of us do, and are interested in our program, please fill out this form:

Subject:

Name:
Mailing Address:
Email Address:
Contact Phone:
Best form of contact:
Website:
How far are you willing to travel to a drop off point?
How did you hear about us?
Other referral:
How important is it to you to be directly connected to the farmer that is growing your food?
Are you interested in hosting a Drop-Off point?	Yes or No
What products are you interested in buying? (check all that apply)	Vegetables Fruit Dairy Flowers and Herbs Honey Syrup Meat Poultry Eggs Nuts Grains
Other products:
What payment methods will you use? (check all that apply)	Cash Check PayPal Debit or ATM cards Credit Cards Barter Invoice or Purchase orders
Other payments:

Please help us determine how many people may be using this service
How many people does your family feed?	Adults: Children:
Age of the adults in the family: (check all that apply)	20-30 years old 30-40 years old 40-50 years old 50-60 years old 60 and up
Age of the children in the family: (check all that apply)	1-5 years old 6-12 years old 13-18 years old 19 and up

Comments:

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