Agreement No. ______
Special Milk Program 2010-2011 Application Form
The ______(Sponsor) is renewing its State approved Application/Agreement for the 2010-2011 school year.
BE SURE TO DUPLICATE ENTIRE APPLICATION/AGREEMENT PRIOR TO MAILING TO ENSURE THAT YOU HAVE A COPY FOR YOUR FILES.
If you operate a Non-Pricing Program the following items must be completed and returned.
1. ______Renewal Form (original signature)
2.______Agreement (original signature)
3.______Application for Participation Sponsor Data Sheet (SMP-2)
4.______Site Data Sheet for EACH SITE operated by the sponsor (SMP-3) – (one for each site) (#of Participating Sites)
sheet if needed).
5.______Copy of your milk procurement contract, documentation of solicitation of milk price
offerings, or a documented explanation of how you chose the supplier of your milk
6.______License for each site, which includes street address, license capacity and expiration date
(if applicable) – (if not applicable, include exemption statement)
7.______Audit Certification
8.______Drug Free Workplace Certification, Signed
9.______Debarment/Suspension Form, Signed
10. ______Copy of 501 (C) (3) from IRS
11.______Copy of License for each site, if applicable (current, if not submit upon renewal)
If you operate a Pricing Program the following items must be completed and returned.
1.______Renewal Form (original signature
2.______Agreement (original signature)
3.______Policy Statement (original signature)
(Application Reviewer and hearing Official different)
4.______Application for Participation Sponsor Data Sheet (SMP-2)
Price of milk
5.______Site Data Sheet for EACH SITE operated by the sponsor (SMP-3) – (one for each site)
(# of participating sites)
6.______Copy of your milk procurement contract, documentation of solicitation of milk price
offerings, or a documented explanation of how you chose the supplier of your milk
7.______License for each site, which includes street address, license capacity and expiration
date (if applicable – if not applicable, include exemption statement
8.______Letter to Household (Attachment A) (Hearing Official same as Policy) prices indicated
9.______Application for Free School Milk (Attachment A-3)
10.______Notification Letter to Parents (Attachment C) (Hearing Official same as Policy)
11.______Audit Certification
12.______Drug Free Workplace Certification (Signed)
13.______Debarment/Suspension Form (Signed)
14.______Copy of 501 (C) (3) from IRS
15.______Copy of license for each site, if applicable (current, if not submit upon renewal)
16.______Collection Procedures
17.______Public Release
______
Signature of Authorized Sponsor Official______
Date
______
Address
______
Perry W. Fulton, Director Date
Child Nutrition Programs
Return to:
Perry W. Fulton, Director
Child Nutrition Programs
5163 GordonPersonsBuilding
P.O. Box 302101
Montgomery, AL 36130-2101