CFO Agency Membership Application

Agency Membership Application
General Information
Agency Name:*
Physical Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Name of Agency Primary Representative:*

PrefixFirst NameLast Name
Title/Position:*
E-mail Address:*
Business Number:*

Area CodePhone Number
Cell Number:*

Area CodePhone Number
Business Website
Is this Organization a:*

Non-Church/501(c)(3)ChurchOther
Federal Employer Identification Number:*
Please state the organization's mission*
Years in operation:*
Required Documentation:

If the organization is a non-church 501(c)(3), please attach/upload a copy of a valid IRS letter of 501(c)(3) determination by clicking the button below.

If the organization is a church or house of worship, please attach/upload a letter on the organization's letterhead, signed by the senior officer (e.g., Senior Pastor, Chair, Board of Trustees, etc.), affirming that the organization meets the 14-point criteria developed by the IRS in defining a church.
Please upload your 501(c)(3) determination letter or church letter of affirmation:*

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Organization Information
What type of service(s) do you provide (check all that applies):*

Prepared Meals ProgramFood PantryEmergency ShelterResidential FacilityDay Care CenterGroup HomeTransitional CenterHomeless CenterOther
Please list the counties/area that you serve in GA:*
Does your program charge a fee to access food or other services?:*

YesNo
If your organization is church/house of worship, your program open to non-members?:*

YesNoNon-applicable
How often do you provide services to members of the community?*

DailySeveral times a weekWeekendsSeveral times a monthOnce a monthOther
Please provide the average number of families you serve each month:*
Service & Authorization Information
Which Caring For Others program(s) are you applying for( check all that applies):*

Food BankClothing Bank
Type of vehicle used to pick food and/or clothing:*
Program Contact Name:*

PrefixFirst NameLast Name
Program Contact email*
example@example.com
Please list up to four individuals who are authorized to pick up products from Caring For Others on behalf of your organization:
Name #1:

PrefixFirst NameLast Name
Cell Phone Number

Area CodePhone Number
Name #2:

PrefixFirst NameLast Name
Cell Phone Number

Area CodePhone Number
Name #3:

PrefixFirst NameLast Name
Cell Phone Number

Area CodePhone Number
Name #4:

PrefixFirst NameLast Name
Cell Phone Number

Area CodePhone Number
By entering my name below, I attest the information provided on this application is true and correct:
Electronic Signature*

PrefixFirst NameLast Name
Title*
Should be Empty: