GOODS Program Recipient Application

GOODS Program Recipient Application

Ambassador - Iowa Humane Alliance
This is an application for organizations within driving distance to Cedar Rapids to apply for donations from the Greater Goods GOODS Program.

Donors provide wholesome, nutritious food on an as-available basis only. GOODS program and recipient organizations are not able to request specific food types (e.g., grain-free) or brands.

Food and supplies (the "Donated Goods") are for the Recipient Group’s use only. They may not be: a) redistributed without the expressed written consent of GOODS, b) sold, rented, or exchanged for other goods or services, nor c) presented for refund.

Each Recipient Organization must complete their own application. Submitting this form does not guarantee approval to receive products. Incomplete applications will not be processed.

Please send an email with a copy of your 501c approval letter to petfoodpantry@iowahumanealliance.org.

Application process may take up to 10-14 days.

Distribution is announced in an initial distribution email. Therefore, it is important to have and check your email regularly for updates from us about distribution days and food availability.

Cost of shipping and handling is currently around 15 cents a pound, (example 1,000 lbs. $150.00)
What is your Organization type?*

Rescue (Foster Based Adoption)Shelter (Brick and Mortar Facility)Pet Food PantryFeral Cat (TNR/Colony Manager)SanctuaryNon-Dog and CatGovernment ShelterAnimal Control Contract
Your Organization Name*
Website*
Website link to adoptable animals (direct link required, Do Not put the word "Petfinder" or petfinder.com).*
(For non-shelter/rescue applicants, please put N/A.)
Facebook Page
Non-Profit Tax ID/EIN#*
Address (same as on IRS letter)*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Completed By*
Applicant's Position in Organization*
Phone Number*
Please enter a valid phone number.
Mission Statement*
Animals reside in:*

Foster HomesFacilityBothN/A
# of Dogs adopted in past 12 months*
# of Cats adopted in past 12 months*
# of Animals routinely under your care*
Average monthly need for Dog food (lbs)*
Average monthly need for Cat food (lbs)*
Describe food storage capabilities - include maximum food storage capacity*
Product Needs - Check All that Apply:*

Dry Dog FoodDry Cat FoodWet Dog FoodWet Cat FoodDurable GoodsWildlife/Farm Supplies
Spay/Neuter all animals prior to adoption*

YesNo*
* If No, please explain why
Briefly describe adoption process*
Facility Location, if any:

Street Address

Street Address Line 2

CityState

Zip Code
Does your organization have a contract to provide Animal Control Services for any city, county, or municipality? If Yes, please explain: *
Veterinary Reference - Please provide contact information*
Have you participated in a "donated" or "low cost" pet food program within the last 12 months?*

Yes*No
* If Yes, please provide program name and frequency:
Please list other food sources*
Why is your organization requesting support from the GOODS program?*
Please list a Personal Reference (Board Member or Supervisor) - Please provide contact information and affiliation:*
If not applicable, please put N/A
How did you hear about our program? (if you were referred, please list the name of the individual and/or organization)*
Authorized Representative #1*
First and Last Name
Position in Organization*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Authorized Representative #2*
First and Last Name
Position in Organization*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
By submitting this application you agree and acknowledge the following terms and conditions:
1.      You are authorized to sign this agreement on behalf of this organization and certify that the information set forth in this application and supporting documentation is correct.

2.       You have read and understood the criteria that apply to this application and certify that the group meets each one.

3.     The IRS determination letter has not been revoked, canceled or modified.

4.     That food shall be protected against dampness, deterioration, and mold or from contamination by insects, birds, rodents or other animals

5.     That food spoiled or otherwise contaminated shall not be served.

6.     To abide by restrictions or conditions of distribution, if any, imposed by the source of Donation and communicated to Recipient by Donor.

7.     Any raw meat provided is not fit for human consumption and shall be used solely for feeding animals.

8.     That feeding pet food to ruminant animals is prohibited.

9.     To not sell, transfer, trade or barter any Donation or portion thereof in exchange for money, property or services or otherwise allow the items to enter commercial channels.

10.   To release both Donor and Donor’s source(s) from any liability arising from the condition of Donation and further agrees to indemnify and hold harmless Donor and its source(s) against any and all damages, losses, claims, causes of action and suits of law or in equity or any obligation whatsoever arising out of or attributed to any action of in connection with Recipients receipt, handling or distribution of Donation.

11.   That GOODS may list your organization as a participant in its publications, website or other informational materials but will not sell or disclose non-contact information for any commercial purpose.

12.   That goods or services are provided on an "as is" and "as available" basis. GOODSSM expressly disclaims all warranties of any kind, whether express or implied, including, but not limited to the implied warranties of merchantability or fitness for a particular use or purpose.

13.   Your organization grants to GOODSSM the following: 1) the right to include on its website a link to your organization’s website(s), 2) the right to use any image(s) that you submit to GOODS or that may be recorded by GOODSSM during or in connection with events that involve both organizations.

14.   Permit monitoring, including a site visit if requested, by a Donor representative, as reasonable and necessary to verify that compliance with criteria, receipt, handling and use of Donation conform to this Agreement.

15. Applicant grants permission to GOODS and its pet products donors to use information contained in this application for their internal evaluation and response procedures.

16. All Handling Fee payments are to be made prior to distribution or if amount unknown until after distribution, with-in 24 hours of pick up or notification.
I have read and agree to the terms and conditions described in this application.*

Yes
Type Full Name Here*
Date*

MonthDayYear
Date
Should be Empty: