Attachment_B_Consent_Form.pdf

ATTACHMENT B OF

TASK ORDER PERFORMANCE WORK

STATEMENT (PWS)

CONSENT FORM

SNAP STORE VISIT CONTRACT

U.S. Department of Agriculture - Food and Nutrition Service

STORE REVIEW CONSENT FORM

FNS #

I, , give my consent for FNS or its Contractor to (Print name) review this store – to take photographs, to sketch the store layout, and to collect other information in connection with this store’s participation in the Supplemental Nutrition

Assistance Program (SNAP).

Signature Date Title

STORE REVIEW REFUSAL FORM

Note: If you do not allow a store review to be conducted, your application may be denied or your permit may be withdrawn.

I, , refuse to give my consent for a store review and (Print name) understand that my refusal means that this store will not be eligible to participate in the

Supplemental Nutrition Assistance Program (SNAP) without a complete review.

Signature Date Title