Partner Account Profile

Partner Account Profile
This form is intended for use by both new and existing partner agencies.

If you are a newly approved Partner Agency with Second Harvest - complete this form in its entirety.

If you are an existing Partner Agency that needs to make some profile updates - complete only the fields that have changed.
Partner Program Account Information
Program Name
Program Number
Address

Mailing address

Address 2

CityCounty

Postal / Zip Code
Distribution site (if different from address)
Storage site (if different)
Population providing service to
How many times can someone visit your panty/program each month?
Food Safety
Person responsible for Food Safety
Food HandlerManager
FOOD HANDLER Certificate Issue Date

MonthDayYear
Date
Food SAFETY MANAGER Certificate Issue Date

MonthDayYear
Date
Food SAFETY MANAGER Certificate EXPIRATION date

MonthDayYear
Date
Billing Contact Information
Billing Contact Name
Role/Title
Phone 1
Format: (000) 000-0000.
Phone 2
Format: (000) 000-0000.
Mailing address
Email address
example@example.com
Delivery/Site Information
Delivery (free, but requires a minimum poundage)Pick up at Second Harvest Distribution CenterHybrid: utilize deliveries and pickups
Site Name
Site/Distribution Address

Street Address

Street Address Line 2

CityCounty

Postal / Zip Code
Contact Person Name for calls (delivery time, issues day-of, etc.)
Contact Phone
Contact Email
Key Contacts
#1 Contact Name
Role/Title
Phone 1
Format: (000) 000-0000.
Phone 2
Format: (000) 000-0000.
Mailing address
Email address
example@example.com
YesNo
InvoicesNewsletterRecall InformationDeliveries
#2 Contact Name
Role/Title
Phone 1
Format: (000) 000-0000.
Phone 2
Format: (000) 000-0000.
Mailing address
Email address
example@example.com
YesNo
InvoicesNewsletterRecall InformationDeliveries
#3 Contact Name
Role/Title
Phone 1
Format: (000) 000-0000.
Phone 2
Format: (000) 000-0000.
Email address
example@example.com
Mailing address
YesNo
InvoicesNewsletterRecall InformationDeliveries
MealConnect (aka Fresh Connect)
Please list below your MealConnect partner stores:
SundayMondayTuesdayWednesdayThursdayFridaySaturday
Additional Information
YesNoAlready doesOther
Other Second Harvest partners with whom you sometimes share excess product (theirs or yours):
Second Harvest Mobile(s) where you pick up leftovers:
Other regular sources of donated food:
Additional Information you'd like to provide:

Your Monthly Distribution Schedule (add times of distribution in the correct cell - ex. 4pm - 6pm)*

Rows	Sun	Mon	Tues	Wed	Thur	Fri	Sat
1st Week
2nd Week
3rd Week
4th Week
5th Week

Partner Coordinator Full Name*
Partner Coordinator Signature:

Clear
Date

MonthDayYear
Date
Should be Empty:

Partner Account Profile

Partner Program Account Information

Food Safety

Billing Contact Information

Delivery/Site Information

Key Contacts

MealConnect (aka Fresh Connect)

Additional Information