Retail Partner Interest Form

Retail Partner Interest Form

Thank you for your interest in being a retail partner with Double Up Food Bucks Mississippi. You are invited to complete this form to start the process of being considered as a new retail partner with our SNAP incentive program.

In what zip code is this site located?*

If this is a mobile market, enter all zip codes where the market operates.

In what county is this site located?*

If this is a mobile market, enter all counties where the market operates.

SNAP/EBT and Benefits Programs

To be eligible, all locations must currently be accepting SNAP/EBT.

Does this site accept SNAP/EBT?*

Yes

No

How long has this site accepted SNAP/EBT?*

Applying for SNAP*

You answered that you don't currently accept SNAP. Have you applied or do you have plans to apply with USDA to become a SNAP-authorized retailer? Let us know where you are in this process.

Have you ever run a SNAP incentive program before at this site?*

Yes

No

Tell us a little about your previous SNAP incentive program.*

For example: when did it operate, for how long, why did it end, how successful was it, etc.

Reason for interest*

Tell us why you are interested in offering a SNAP incentive program at your site.

Location and Hours of Operation

What is the name of your store or market?*

Type of Site*

Farmers Market

Mobile Farmers Market

Produce Stand

Private Farm/Farmer

Grocery Store

Other

OTHER Type

If you selected "Other", please specify here.

Organization Type

Select or enter value

How long has this site been operating?*

When do you operate?*

Seasonal

Year-Round

What days of the week do you operate?*

How many hours per day (average) do you operate?*

Please provide the street address where this site is located.*

In what city is this site located?*

Community Engagement and Outreach

Community Engagement*

How would you rate the current engagement level of your local community with regards to your site?

High Engagement

Medium Engagement

Low Engagement

Community Outreach*

Tell us a little about your approach to community outreach, especially in regards to reaching out to lower-income community members who may be eligible for SNAP.

Please enter a link to your business website.*

If you don't have a website, enter "n/a."

Do you utilize social media for this site?*

Select all that apply.

Select

Approximately how many people do you have following your site on social media?*

Please provide a link to your site's Facebook page.*

Please provide a link to your site's Twitter page.*

Please provide a link to your site's Instagram page.*

Scope and Capacity

What is your average, daily attendance?*

What is your average, daily sales?*

List the types of fresh produce you typically have available for sale.*

Approximately how many vendors sell fresh fruit and vegetables at this site?*

Record Keeping and Reporting*

Programs like this require very good record keeping as well as accurate, timely reporting. How would you rate your comfort level with record keeping and reporting?

Select or enter value

Do you have a point of sale provider?*

Yes

No

Who is your point of sale (POS) provider?*

Demographic Information

This section is optional.

What is your gender?

What is your age?

18-34 years old

35-49 years old

50+

How would you identify yourself?

Select or enter value

Contact Information

Please provide us with contact information so we can get in touch with you.

Contact Name*

Contact Phone*

Contact Email*

Thank you for completing this form. Someone will be in touch with you soon.

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