Partner Agency Pre-Screening Form
Contact Information
Name of Organization
*
Contact Person
*
First Name
Last Name
Title
Email Address
*
Phone Number
*
-
Area Code
Phone Number
Program Information
Type of Program?
*
Meals provided or prepared on-site
Food Pantry
Other
Date food assistance program started (or anticipated start date)
*
-
Month
-
Day
Year
Date Picker Icon
Is the organization a 501(c)3?
*
Yes
No
Tax ID Number
Is your food assistance program operated under the umbrella of another 501(c)3 organization or church?
*
Yes
No
Please provide the name of your umbrella organization/affiliation:
Umbrella Organization Tax ID Number
How often does your organization distribute food:
*
Year-Round
Seasonally
Other
Current days and hours of distribution or operation:
*
Number of clients served monthly:
*
What are your current sources of food? (select all that apply)
*
Purchased
Donations from Retail Stores
Donations from Individuals (i.e. Food Drives)
No food sources at this time
Other
Is your food program managed/coordinated by:
*
Paid Staff Only
Volunteers Only
Both Paid Staff & Volunteers
Would you be interested in becoming a Produce-Only Distribution Partner for NTFB?
*
Yes
No
Unsure
If requested, can you provide documentation of your client screening process and a client list or roster?
*
Yes
No
If requested, can you provide a copy of your most current budget for your food assistance program?
*
Yes
No
Geographical Information
County and zip code where food distribution takes place
*
List all zip codes that your program serves
*
Physical address (including county) of food distribution site(s)
*
Physical address of non-food distribution sites (if applicable)
*
Please list any NTFB Partner Agencies within a 10-mile radius of your physical distribution address that you are aware of:
Additional Comments
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