Equipment Grant Survey
Response to this survey does not guarantee equipment grants! We will follow up with additional information.
Agency Name
Contact Email
example@example.com
County
Lackawanna
Luzerne
Susquehanna
Wyoming
What kind of cold-storage equipment are you requesting?
We typically offer one, two and three door refrigerated or frozer units.
What kind of cold-storage equipment are you requesting?
1 door cooler
2 door cooler
3 door cooler
1 door freezer
2 door freezer
3 door freezer
Request details - if requesting more than one unit, please tell us which is your first choice/top priority. The number of units granted is based on availability of funds.
Is this your agency's first cold storage unit?
Yes
No
First cooler, but we have a freezer
First freezer, but we have a cooler
If you have other cold storage, please describe:
Include cooler/freezer, size of the units, and number of units
Do you have the necessary electrical wiring to add the requested cold storage equipment?
yes
no
not sure
Choose the schedule below that best describes when you are opent
once a month
twice a month
once a week
two days a week
three days a week
four days a week
five days a week
Other
Is food available upon request outside of regularly scheduled hours?
Yes
No
On average, how many total households do you serve each month, including repeat visits within the same month.
100 or less
101-200
201-300
301-400
401-500
500-1000
1000+
Submit
Should be Empty: