Agency Application For

Agency Application for

Second Harvest Food Bank of Middle Tennessee

Date: Contact Person:

Agency: ______

Mailing Address: ______

Street Address: ______

City: ______Zip:______County:______

Parent Organization: ______

Agency Director: ______Phone No.______

Contact Person Email Address: ______

Direct Monthly Statements To: ______Phone No.______

Agency fax number: ______Email Address: ______

Days and Hours of operation: ______

Maximum serving capacity: ______

Second Harvest program applying for: Community Food Partner Middle TN’s Table Mobile Pantry

Please indicate which description fits your program (check all that applies):

_____On-Site meals _____Home-bound meals _____ Food pantry

AGENCY RECORDS

The following information is necessary to process your application. Please attach a copy of all applicable documents.

A copy of agency charter or by-laws

A list of board members with addresses and phone numbers

Mission statement on agency letterhead

A copy of any certification or licensing necessary for the operation of the program (if applicable)

A brochure or other information which provides a program overview

Client application form

List of food box contents (if applicable)

Current 990 submitted to Internal Revenue Service OR Three (3) Months Current Financial Statement (if not required to file 990)

____ State sales tax exemption certificate

A letter from the Internal Revenue Service stating that agency has the tax-exempt (501c3) status

(not a state tax-exempt/ must be dated later than 2007)

A current copy of the Food Service Training Certificate from the local Health Department or UT Extension (required only if providing on-site feeding)

____ $25 non refundable application fee (if not currently a Community Food Partner)

TARGET GROUPS

All foods distributed through Second Harvest Food Bank are intended to provide for the needy, the ill, the elderly, and homeless or needy children. Indicate the program (s) that you operate:

Homeless Shelter: Residential? Yes or No

Serving: Men______Women Adolescents_____ Children____ Families_____

Counseling/Rehabilitation Center: Residential? Yes or No

Serving: Men______Women Adolescents_____ Children____ Families______

Senior Program: Residential? Yes or No

Youth Program: Residential? Yes or No

Child Care:Day Care or After School Program

Soup Kitchen

______Food Pantry

Indicate what county/counties you serve:______

How would you describe the people your program serves?______

______

Eligibility requirement: ______

______

Program goals: ______

FOOD SERVICES

IF YOU SERVE MEALS:

Days meals are served:

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Average number of CLIENTS served EACH MEAL. If staff joins the clients for meals, indicate that number in parentheses.

______Breakfast______Lunch______Dinner______Snack

IF YOU DISTRIBUTE FOOD BOXES:

(Please include client application and list of typical food box contents with paperwork.)

Number of food boxes distributed each month:

Number of individuals served each month:

Food vouchers used for perishables: Yes No

Percentage of the congregation receiving food boxes: (If pantry is operated by a church

IF YOU OPERATE A CHILD CARE PROGRAM:

(Please send a copy of current state license with paperwork)

Number of children licensed:______

Number currently enrolled:______

Program includes (Please check all that is applicable):

______Infants

______Pre-School Children

______Before/After School Program

______Summer Program for School Age Children

How many caregivers work with your day care program?______

AGENCY FUNDING

Please indicate the sources of agency funding. Give the approximate percentage of each.

FUNDING SOURCES SHOULD EQUAL 100%

______United Way______Client Fees

______Private Donations______CACFP Program

______Government grants/funding* ______Other: ______

*If your program receives 100% governmental funding, please explain in detail.

______

______

Clients in your program must not be charged for, or requested to perform services in exchange for foods your agency receives from Second Harvest Food Bank. If client fees are used in your program, please explain in detail.

______

FOOD STORAGE

Kitchen supervisor or cook:______

Please give an estimate of the storage capacity that will be used exclusively for this program:

Refrigerated:______

Frozen:______

Dry Storage:______

AGENCY PICK UP

Only the following individuals are authorized to pick-up your food order.

1.______2. ______

3.______4. ______

AGREEMENT for

COMMUNITY FOOD PARTNERS

As the authorized representative(s) for the private, non-profit organization named below, I understand Second Harvest Food Bank will provide available foods and related items to my organization with the understanding that:

1. The organization will use the products obtained from the food bank solely for the feeding of the ill, needy or infants and this use will be related to its federal tax-exempt purpose as a 501c3 organization. ______Initial

1. The organization will neither sell, transfer, nor barter items supplied by the food bank in exchange for money, property or services or otherwise allow the items to enter the commercial market. This also applies to USDA product. (Transfer means: for example, an agency which has an extension of their program in another town or county cannot transfer product to that extension unless approval has been received from the Agency Relations Department of Second Harvest Food Bank.) ______Initial

1. The organization will pay Second Harvest $.25 per pound*shared maintenance fee on Grocery Recovery Meat,$.18 or less on all other donated product and Co-op fees are for purchased product by Second Harvest from other manufacturers. The Rural Delivery Program has a delivery charge of $.06 per pound of food delivered with a maximum delivery charge of $150.00. ______Initial

1. Organizational check only. No cash, personal checks, or money orders. ______Initial

1. The organization will utilize employees or volunteers with sufficient training and experience to insure the integrity and palatability of all food items received from the Second Harvest Food Bank. ______Initial

1. The organization recognizes Second Harvest Food Bank and the primary donor have specifically disclaimed any warranties, expressed or implied, as to the purity of fitness for consumption of any donated items. Food usage is solely at the discretion of the receiving partner agency.The organization will accept all products in “as is” condition. ______Initial

1. The organization recognizes the food received from Second Harvest Food Bank is intended solely for the clients in your program as stated within application. ______Initial

1. The organization will notify Second Harvest Food Bank of any organizational changes such as, director, food coordinator, telephone/fax numbers, etc. within 30 days of changes. ______Initial

1. The organization releases the original donor, the food bank and Feeding America from any liabilities resulting from the donated products.______Initial

1. The organization agrees to hold harmless from any claims or obligations in regard to the agency or the donated goods, the original donor, the food bank or Feeding America.______Initial

1. The organization prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived from any public assistance program. ______Initial

*The .07/lb represents a value added packaging (VAP) fee that is incurred due to the fact the product is sorted by meat category, UPC marked through, and boxed by category at the food bank for your convenience.

Signature of Authorized Representative:______

Name of Organization:______Date:______

1

331 Great Circle RoadNashville, TN37228 Phone: (615) 329-3491 Fax: (615) 329-3988