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MARKETING AND DEVELOPMENT

Virginia Farm to School Program ~ Distributor Form

Photo of truck.

School Form
Farm Form
Distributor Form

Register Now

Distributor Form
Date:

Company Name:

Contact Person and Title:

Address:

City/County:

State:

Zip:

Phone:

Fax:

E-mail:

Web site:

Please list the counties or regions (see map) you are interested in servicing:

Region: (See map for details)
1 2 3 4 5 6

Shipper Codes:
CA CS GAP HC ICE LTL
TL

Distributors of:
Fruit Vegetables Dairy Eggs Meat Seafood Other:

Requirements for Shipping from Farms (Check all that apply):
Gap Certification Liability Insurance Other:

Business Description (i.e. mission statement, family business, etc.):

 
or

Please feel free to contact Leanne DuBois with any questions at leanne.dubois@vdacs.virginia.gov or dial 804.225.3663. You can also fax registration forms to 804.371.7786. Thank you.

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