GLM-RFBC Logo
Service Provider Registration Form
Data Transparency and Consent

Dear service provider:

The Great Lakes Midwest Regional Food Business Center (GLM-RFBC) invites service providers to share their information as we build a network to support food and farm business entrepreneurs across the Great Lakes Midwest region (MI, IL, IN, WI). The information collected in this registration form will help us determine your eligibility to work with these entrepreneurs and, if suitable, connect you with relevant opportunities and/or add you to our database of service providers. The form will take approximately 20 minutes to complete.

Can I stop completing this form at any time?
Completing this registration form is voluntary, and you may choose not to take part at all or stop at any time. If you decide not to complete the form, we will not contact you about future opportunities. Your decision will not affect any future benefits for which you may qualify through the GLM-RFBC.

Why is this information being collected?
This form will gather information about your business or organization, the services you provide, references for those services, and demographic information about the owners or leadership, including age, race, ethnicity, and gender identity. The information you share will have identifying information (including your name, your business name, street address, and contact information) removed. The remaining information will be aggregated and shared through reporting to the project funder, the United States Department of Agriculture (USDA). The information, shared in semi-annual reports, will be used to demonstrate overall program impact, reach, and outcomes and help to inform future assistance offerings and resources. For more information about the USDA’s evaluation plan and data use policies, please visit the USDA Regional Food Business Center Frequently Asked Questions - Center Evaluation and Impact tab. https://www.ams.usda.gov/services/local-regional/rfbcp/faq.

What are the possible risks or benefits from completing this form? 
There are no known risks to completing this form. The information collected may not benefit you directly. The information learned may be helpful to others like you in the future. You will not be compensated for your time or inconvenience for completing the form.

How will my information be protected?
The information you provide will be kept private and secure by storing it on a password protected computer in a secure online data storage platform to ensure individuals outside of the GLM-RFBC cannot access it. Please find a private and safe location to complete the form to ensure the privacy of your responses. Your information will be collected using FormAssembly and stored on Salesforce.com. FormAssembly and Salesforce.com meet stringent security standards and compliance requirements like ISO 27001 and General Data Protection Regulation (GDPR). Authorized individuals from the GLM-RFBC, including staff from the Michigan State University Center for Regional Food Systems, which coordinates regional activities and those in Michigan, and its key partners - Chicago Food Policy Action Council (IL), Northwest Indiana Food Council (IN), Food Finance Institute of the University of Wisconsin System (WI), and the Menominee Indian Tribe of Wisconsin Department of Agriculture and Food Systems (regional tribal coordinator) - may review, inspect, and use these records. In all other respects, however, the information you provide will be held in confidence to the extent permitted by law. Should this information be published, including through reports, dashboards, and general location mapping, your name, your business name, street address, and contact information will not be disclosed.
     
By clicking on the statement below, you agree to enter your information into the service provider registration form that follows. If you have any questions, concerns, or complaints about the form, please contact Eva Nyerges at nyergese@msu.edu or Jahi Johnson-Chappell at chappe17@msu.edu.

If you choose not to participate at this time, please close this browser tab or click the link below to return to the GLM-RFBC homepage. Your information will not be recorded. You may revisit this page at any time if you opt to participate in the future.

GLM-RFBC Logo
Service Provider Registration Form
Business Contact Information







Business or Organization Address









Mailing Address (If Different from Business Address)













GLM-RFBC Logo
Service Provider Registration Form
About the Services you Provide




















GLM-RFBC Logo
Service Provider Registration Form
About your Business








Please provide the date in mm/dd/yyyy format. If you do not know the exact month and day, please enter 01/01 and then the year your business was established. If you have a EIN, you can also check the date on your IRS documents.


Underserved Communities
“Underserved communities” are defined by the USDA as populations sharing a particular characteristic, as well as geographic communities, that have been systematically denied a full opportunity to participate in aspects of economic, social, and civic life, such as: 
--Black, Latino, and Indigenous and Native American persons, Asian Americans and Pacific Islanders and other persons of color; 
--members of religious minorities
--lesbian, gay, bisexual, transgender, and queer (LGBTQ+) persons; 
--persons with disabilities; 
--persons who live in rural areas; and 
--persons otherwise adversely affected by persistent poverty or inequality.) 

For more information about the use of this term, visit USDA DEIA Strategic Plan.





GLM-RFBC Logo
Service Provider Registration Form
About You
The following demographic questions serve to deepen our understanding about the impact, reach, and need of our services. Responding to these questions is voluntary and will not impact your registration. Your responses to these questions will not be shared with the USDA.







GLM-RFBC Logo
Service Provider Registration Form
Other Business Information



References
Please provide the name and contact information of at least one reference who can speak to the services you are offering and their quality. References from a farm or food business are encouraged.






If you would like, please provide the name and contact information of an additional reference who can speak to the services you are offering and their quality. References from a farm or food business are encouraged.






Contact Preferences



Contact Information