Name of Farm:

Contact Name:

Farm Street Address 1:

Farm Street Address 2:

City:

State:

Tennessee Non-US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

County:

Select County ANDERSON BEDFORD BENTON BLEDSOE BLOUNT BRADLEY CAMPBELL CANNON CARROLL CARTER CHEATHAM CHESTER CLAIBORNE CLAY COCKE COFFEE CROCKETT CUMBERLAND DAVIDSON DECATUR DEKALB DICKSON DYER FAYETTE FENTRESS FRANKLIN GIBSON GILES GRAINGER GREENE GRUNDY HAMBLEN HAMILTON HANCOCK HARDEMAN HARDIN HAWKINS HAYWOOD HENDERSON HENRY HICKMAN HOUSTON HUMPHREYS JACKSON JEFFERSON JOHNSON KNOX LAKE LAUDERDALE LAWRENCE LEWIS LINCOLN LOUDON MACON MADISON MARION MARSHALL MAURY MCMINN MCNAIRY MEIGS MONROE MONTGOMERY MOORE MORGAN OBION OVERTON PERRY PICKETT POLK PUTNAM RHEA ROANE ROBERTSON RUTHERFORD SCOTT SEQUATCHIE SEVIER SHELBY SMITH STEWART SULLIVAN SUMNER TIPTON TROUSDALE UNICOI UNION VAN BUREN WARREN WASHINGTON WAYNE WEAKLEY WHITE WILLIAMSON WILSON

Mailing Street Address 1:

Mailing Street Address 2:

City:

State:

Tennessee Non-US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:

County:

Select County ANDERSON BEDFORD BENTON BLEDSOE BLOUNT BRADLEY CAMPBELL CANNON CARROLL CARTER CHEATHAM CHESTER CLAIBORNE CLAY COCKE COFFEE CROCKETT CUMBERLAND DAVIDSON DECATUR DEKALB DICKSON DYER FAYETTE FENTRESS FRANKLIN GIBSON GILES GRAINGER GREENE GRUNDY HAMBLEN HAMILTON HANCOCK HARDEMAN HARDIN HAWKINS HAYWOOD HENDERSON HENRY HICKMAN HOUSTON HUMPHREYS JACKSON JEFFERSON JOHNSON KNOX LAKE LAUDERDALE LAWRENCE LEWIS LINCOLN LOUDON MACON MADISON MARION MARSHALL MAURY MCMINN MCNAIRY MEIGS MONROE MONTGOMERY MOORE MORGAN OBION OVERTON PERRY PICKETT POLK PUTNAM RHEA ROANE ROBERTSON RUTHERFORD SCOTT SEQUATCHIE SEVIER SHELBY SMITH STEWART SULLIVAN SUMNER TIPTON TROUSDALE UNICOI UNION VAN BUREN WARREN WASHINGTON WAYNE WEAKLEY WHITE WILLIAMSON WILSON

Phone:

(include area code)

Fax:

(include area code)

Sales Person:

Sales Person Number:

(include area code)

E-mail:

Web site URL:

Loading/dock hours:

Please list me under the following:

• Choose all that apply.
• Pick Your Own
• Wholesale
• Farm Market

Please list the wholesale crops you grow and the harvest dates below.

I give my permission to the Tennessee Department of Agriculture, Market Development Division, to use this information for a wholesale marketing directory and internet web page.

I Certify.