Food Bank Application

Food Bank Application
Select your Food Bank from the dropdown list, confirm and enter all information correctly in the fields below.
Autocomplete All Fields
Food Bank Name
Food Bank Address
Food Bank City
Food Bank State
Food Bank Zip Code
Coordinator Name
Coordinator Title
Coordinator Email
example@example.com
Coordinator Phone
Format: (000) 000-0000.
Number of individual households fed by your Food Bank.
Total number of member pantries your Food Bank serves.
Number of food pantries that received dog food this year
Total pounds of dog food distributed to pantries this year
Total pounds of pet food last reported to Feeding America
Shared Maintenance Fees for Dog Food (eg. 0.12 cents per pound):
Enter 0 if food bank does not have shared maintenance, and therefore does not meet grant requirements.
I understand the Jazzy’s Place grant can only be used to offset the shared-maintenance costs of dog food acquired by member partner food pantries. These grants cannot be used for any direct or outside purchases of human or dog food.
Has Shared Maintenance Fee
Name
Printed Name
Title
Type Name as Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearApplication Date
Please complete all information in the form above and review for accuracy. Then click the button below to proceed to officially sign and submit your application to the Caplan-Bensley Foundation.
Should be Empty: