Request for a New Distribution Location
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Name:
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County:
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Address:
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City:
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Zip Code
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Email:
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Phone:
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Please identify yourself as one of the following:
Organization
Business
Individual
Practitioner
Buying Club
Other
Please describe your organization, business, etc.:
Website:
Please list the social networks you are a member of (i.e. Facebook, Twitter, etc.):
Where did you learn about us from?
Are you currently a customer?
Yes
No
If available, would you want home delivery?
Yes
No
Do you have any suggestions for businesses or churches that would be willing to host a CSA Farmers Market Pick-up Location?
Yes
No
Suggested locations (please give address, if available):
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