Farmers Market Wellness Vendor Payment Name(Required) First Last Company Name or DBAEmail(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone(Required)Wellness Vendor Fee Quantity(Required) Price: $25.00 Quantity Enter the quantity of dates that you have been approved for by Farmers Market staff. Payment will be completed using(Required) PayPal Check sent by mail Please make checks out to: Sheboygan County Interfaith Organization To complete your payment, please mail the check to: SCIO Attn: Farmers Market PO Box 73 Sheboygan, WI 53082Total