Company/Farm Name:

Contact Name:

Street Address:

City:

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

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:

Phone:

(include area code)

Fax:

(include area code)

E-mail:

Web site:

Type of Business:

Select One Manufacturer Cooperative Wholesaler Farmer’s Market Producer Retailer Processor Other

If other, explain:

How are your products sold?

Select One Wholesale Only Retail Only Both Retail and Wholesale

Preferred Markets:

Specialty Grocer

List products and approximate volumes being promoted using the Pick TN Products logo.

Are the major ingredients of your products being grown in Tennessee? Yes No

Where are they grown?

Are your products processed in Tennessee? Yes No

Where Are they processed?

Where are they packaged?

What product subheading would you like to be listed under?

Do State or Federal Organizations Inspect or License your Products or Facilities? Yes No

Are You Interested in Participating in Tradeshows? Yes No

Are You Interested in Exporting? Yes No

Do You Want to Display the “Pick Tennessee Products” Logo on Your Product(s)? Yes No

How Did You Find Out About the Pick Tennessee Products Program?

• Select One Tradeshow PTP Staff PTP Website Referred By Current PTP Participant Other
• If other, please explain:

Guidelines for Use of the "Pick Tennessee Products" Logo

Products bearing the PTP logo must be high quality agricultural products produced or processed in Tennessee. Changes in logo composition or colors must be approved by the marketing division. All products bearing the logo must meet or exceed U.S. Government and or State of Tennessee standards where applicable. The right to use the logo is personal only to the applicant and cannot be reassigned without approval of the TDA Market Development Division. Permission to use the logo may be revoked at any time. The State of Tennessee is in no way liable for, nor does the state guarantee, products using this logo.

I certify that I have completed the application and read the guidelines set forth by the Tennessee Department of Agriculture Market Development Division.

I Certify.