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Form D: Change To Agency Information
Agency Number:
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Agency Name:
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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.
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Mailing Address
Contact Person Phone
Type of Program
Authorized Individuals
Distribution Address
Agency Phone
Contact Email
Services Provided
Population Served
Billing Address
Contact Name
Agency Fax
Program Schedule
Website/Homepage
Site is Closing
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.
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Please list all authorized food distribution program personnel (Full name and title/function):
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By signing this you are certifying that you are authorized to make changes to the agency account
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First Name
Last Name
Submit
Should be Empty: