Food Assistance Provider Form

If you are a non-profit, charitable food assistance provider, please complete this form.
Fields In RED are Required Fields. Please Complete

Agency Name:

Mailing Address:  City:  Zip Code:

Physical Address:  City:  Zip Code:

County Where Located: Email:

Phone Number:   Fax Number:

Contact Person:  Title:

Counties Served:

What type of food program does your agency run? [Check at least one and any others that apply.]

Soup kitchen

Food pantry or food bank 

Other type of food distribution program

       [Please Describe]:

Additional Information About Your Agency

(A) When can customers typically get food from your agency?

Monday

Hours:

Tuesdays

Hours:

Wednesdays

Hours:

Thursdays

Hours:

Fridays

Hours:

Saturdays

Hours:

Sundays

Hours:

(B) During a "typical" week, your agency provides food to about how many people?

people (estimate number of people)

(C) Please indicate the typical make-up of the people to whom your agency typically provides food. [Check the typical group of people, if any.]

Overall people in need

Families with children

Children (under age 18)

Senior citizens (age 65+)

Homeless people

Other group [Please describe]:   

(D) Which of the following equipment does your agency already have for food? [Check all that apply.]
	Refrigerator/cooler
	Freezer
	Refrigerated transport
	Transport, not refrigerated
	Transport for large donations (such as pallets)
	Equipment to can or dehydrate
	None of these
(E) Which of the following are you interested in receiving? [Check all that apply.]
	Salvaged fresh produce through the Share Our Surplus program
	Venison or other wild game meat donated through the Hunters for the Hungry program