Farm Share, non-profit food-bank, for recovery and distribution of surplus food for hungry people

Farm Share Agency Application

October 1, 2006 - September 30, 2007

Please provide all of the requested information and answer all questions below. Submit the completed form to Farm Share with a copy of your 501(c)3 IRS Determination Letter.

If your letter is older than five years,
you must write the IRS requesting an update on your status as a non-profit agency.
* Denotes a Required Field

1. Agency Information

* Organization Name
* Director Name		* Email Address
* Phone Number		Fax Number
* Address
* City		* State
* Zip 5 or 9 digit format		* County
Food Delivery Address If different
Delivery City If different		Delivery State If different
Delivery Zip If different		Delivery County If different
* 1st Delivery Contact		* 1st Phone Number
2nd Delivery Contact		2nd Phone Number
3rd Delivery Contact		3rd Phone Number

* 2. Description of Agency

Soup Kitchen (cook and prepare food that is distributited as meals)
Distribution Center (distributed canned and packaged goods)
Other (please describe)

* 3. Indicate whether your orginaization is Pubic or Private

Public

Private / Non-Profit

* 4. List Counties Served
You must Specify at least one county.

* 5. How often to you distribute food

Daily
Weekly Specify Days	Mon.	Tue.	Wed.	Thurs.	Fri.	Sat.	Sun.
Bi-Weekly Specify Days	Mon.	Tue.	Wed.	Thurs.	Fri.	Sat.	Sun.
Monthly Specify Days	Mon.	Tue.	Wed.	Thurs.	Fri.	Sat.	Sun.
Other (please describe)

* 6. How many Agencies do you serve? Please specify the details of each agency.

7. Please check all requirements that apply.

Church or Government Agency without 501c3.
Upload 501(c)(3):	Distribute food free of charge to end users
Serve primarily people living in poverty	Follow all applicable safe food handling guidelines
Other * (please describe)

* 8. Does you agency conduct direct food distributions to individuals?

Yes Please Describe
No Please Describe

* 9. Are there specific days that you would prefer to receive food?

Yes	Mon.	Tue.	Wed.	Thurs.	Fri.
No, Any Day

* 10. Can you receive food during the weekend?

Yes (select at least one day)	Sat.	Sun.
No

* 11. Does your agency charge any type of fee for food (shared maintenance, etc.)?

Yes Please Describe
No

12. Please indicate which of the following you have access to? And how many of each? Checked boxes require a number.

Walk-in refrigerator		Walk-in freezer
Commercial refrigerator		Commercial freezer
Household refrigeration		Household freezer (front-open)
Household refrigeration/freezer		Household freezer (top-open)
Refrigerated Truck		Dry Truck

* 13. Is your agency able to pay shipping charges for food delivery when necessary?

Yes
No Please Describe

TERMS & CONDITIONS

Farm Share, Inc., a Florida non-profit corporation, provides food to organizations feeding the needy. Farm Share’s intent is to provide this food at no cost to the recipient agency or to the ultimate consumer.

As a Farm Share recipient agency, you hereby agree:

To freely give food to those in need or to agencies feeding the needy and that no fees or expenses of any kind will be a condition for receiving food from your organization.
To not sell, barter or trade this food nor use it for any type of fundraising.
To prevent this food from being an item that competes in the profit-making channels normally used by commercial food distributors.

* I agree to the above Terms & Conditions

* Executive Director/Chairman

Date

07/25/2008