Application for food distribution

Name of agency/organization

Address of agency/organization

Contact person

Position/Title

Email

Phone

Number of paid staff

Number of volunteer staff

Type of agency

Private non-profit Public non-profit For-profit Government agency

Select a Program(s)

USDA Food Distribution CFA/Soup Kitchen Campus Cupboard Community Pantry Program Senior Choice

Tax Exempt #

Attach your IRS determination letter

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Liability insurance carrier

Attach your agency's brochure or fact sheet if available

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What is the specific geographic area that you serve?

Does your organization provide meals on your premises?

Yes No

Days and hours of food distribution. If you are not currently distributing food, please state your 'planned' distribution times.

If yes, how often?

Daily Weekly Monthly Other

Please provide the average number of people served for each meal.

Breakfast

Lunch

Dinner

Does your organization distribute emergency food boxes?

Yes No

How many families do you plan to serve with this food each month?

What other services do you provide?

Who is eligible for your services?

Provide the percentage of food obtained from various sources (please ensure this adds up to 100%). Enter '0' for any field that do not apply to you.

Direct food purchases

Retail store donations

Food drive donations

USDA commodities

Other (specify)

Please provide the dimensions of any storage facilities that your agency has (for example, 20' X 10'). Enter '0' for any of these facilities that you do not have.

Refrigerated

Frozen

Dry

Do you have transportation to our food bank?

Yes No

Please describe your transportation.

Please provide a concise description of your agency/program.