Name * First Name Last Name Email * Business Name (if applicable) Contact Phone Number * (###) ### #### Business website (if you have one) http:// I intend to sell the following items (check all that apply) * Fresh, uncut, whole, unprocessed fruits or vegetables Raw/unadulterated honey Meat, fish, poultry, eggs, and dairy products including natural cheeses Edible grains, nuts and berries Baked goods Prepared foods Food demonstration or food prepared and served on site Cut flowers, seeds, or plants Artwork and handmade goods Wellness services (massage, acupuncture, etc.) Other (fill in below) Please briefly describe all products you intend to sell at the market: * I will be offering samples * Yes No For farmers only -please provide a description of farming practices and copies of any certifications I certify that articles offered for sale are locally grown, cultivated, created, produced or prepared * Yes No Not applicable (non-food items only) I am able to provide Proof of insurance in an amount of one million dollars ($1,000,000.00) coverage and form approved by the City. * Yes No Other (Please write-in explanation below) Please explain if you selected "other" in the above question Do you currently have any of the below licenses or registrations through the City of Evanston? (select all that apply) * Farmers Market License Cottage Food License Food Establishment License Business Registration Other (please fill in below) None "Other" license or registrations through the city of Evanston I have read the below guidelines for the Farmers Market License requirements. https://www.cityofevanston.org/government/departments/health-human- services/protect/farmers-market-license * Yes No Please list the dates you would like to participate (every Saturday, specific dates, etc.): Do you have your own table/tent? * Yes No No, but I would like to rent one Thank you! If you are interested in becoming a vendor at the Church & Dodge Market, please fill out the form below: