Osage Nation Farmers' Market Nutrition Program Application

Only one person per form submission. Each eligible WIC participant in your household needs to fill this application out separately.

Name Name First Last
WIC Client Location
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of Birth Date of Birth / MM / DD YYYY
Phone Phone - ### - ### ####
Email
Please check appropriate box according to WIC status:
Read and select the program guidelines if you:

Read and select the program guidelines if you: Have read on the ON Website the list of Farmers and Farmers Market locations. Understand what fruits & vegetables you can receive. Understand you will be shown how to use your coupon/voucher(s) at the time of receipt. Understand that the Farmer/Farmers Market will enter the amount of your purchase. Understand Farmers/Farmers Markets do not owe you change if you do not redeem the full $5. Understand coupon/voucher(s) cannot be traded for money. Understand that you must sign coupon/voucher(s) in front of Farmer or Farmer's Market sales person. Understand that Farmer/Farmers Markets should not charge tax on coupon/voucher(s). Will receive nutrition education when I receive my coupon/voucher(s).
Program Guidelines

Program Guidelines I have read and understood the above program guidelines.
Rights and Responsibilities
Rights and Responsibilities

Rights and Responsibilities I have read the rights and responsibilities under the program.
Applicant/Authorized Rep. Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: How to File a Complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
- mail: U.S. Department of Agriculture
  Office of the Assistant Secretary for Civil Rights
  1400 Independence Avenue, SW
  Washington, D.C. 20250-9410;
- fax: (202) 690-7442; or
- email: program.intake@usda.gov

Osage Nation Farmers' Market Nutrition Program Application

Osage Nation Farmers' Market Nutrition Program Application

Rights and Responsibilities