Form D: Change To Agency Information
Please check the following changes that you will be making to your agency file. Please note that only the primary contact person can make changes to this information.
Contact Person Phone
Site is Closing
Type of Program
Site is Reopening
Truck Delivery Date/Time Change
Truck Delivery Request
Please indicate all new information on the lines provided below. If your site is closing please tell us the reason why and when it will reopen.
Please list all authorized food distribution program personnel (Full name and title/function):
By signing this you are certifying that you are authorized to make changes to the agency account
Authorized Signer Email Address:
Authorized Signer Phone Number
Should be Empty: