APPLICATION FOR MEMBERSHIP

with the

FOOD BANK OF THE ALBEMARLE

P.O. BOX 1704 | ELIZABETH CITY, NC 27906-1704

109 TIDEWATER WAY | ELIZABETH CITY, NC 27909

TELEPHONE (252) 335-4035 | FAX (252) 335-4797 |

Section I: General Information (to be completed by all applicants)

Date:______

Name of Organization: ______

Phone Number: ( ___) ______Fax No: (___)______

Name of Board President: ______Phone: (___) ______

Name of Program Director: ______Phone: (___) ______

Physical Address of Agency:______

City______State______Zip______County______

Mailing Address (if different than physical):______

City______State______Zip______County______

Email Address______

Is the organization incorporated? ___Yes ___No

Does your organization have a tax exempt status under 501 (c) (3) from the Internal Revenue Service? ___Yes ___No

IF YES, PLEASE SUBMIT A COPY OF YOUR DETERMINATION LETTER FROM THE IRS. IF NO, PLEASE CONTINUE WITH SECTION II.

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SECTION II: (Only complete if answered “No” to last question above)

Is your organization part of a larger parent organization? ___Yes ___No

If it is, will your parent organization be legally responsible for the operations and liabilities of your program? ___Yes ___No

Does your parent organization have a tax exempt status under section 501(c) (3) from the Internal Revenue Service? ___Yes ___No

IF YES, PLEASE SUBMIT A COPY OF THEIR DETERMINATION LETTER FROM THE IRS. Parent organization must submit a letter on their letter head which states their sponsorship of the program. The Director of the sponsoring parent organization must also attend orientation.

Parent and/or Member Organization’s Name (if applicable):

______

Phone Number: (___) ______Fax Number: (___)______

Mailing Address of Parent Organization:______

City______State______Zip______

Name of Chairperson/Board President: ______Phone No______

Name of Director: ______Phone No______

SECTION III: FEEDING PROGRAM (to be completed by all applicants)

Please select the category that accurately describes your program (Please check all that apply):

____ Pantry - (providing groceries to those in need of supplemental or short-term food assistance)

____Mobile Food Pantry- (a way to distribute food to those in need without having a fixed facility)

____Soup Kitchen- (cooking and serving meals to walk-in guests on a regular or occasional basis

____Residential Program- (cooking and serving meals to registered clientele; including Detox, Half-way homes, Group homes, Day Activities Programs)

____Emergency Shelter - (An agency providing on-site meals in addition to providing housing and other services).

____ Day Care- (An organization that provides care and supervision to children while their parents or guardians are at work or in

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____ Children & Youth (An organization that provides service to children under the age of 18.)

____Other - Animal Shelters, Housing Authorities and Senior Sites.

____ Disaster - American Red Cross, Baptist Men, Temporary Pantries for disaster relief.

Please describe the basic purpose of your organization and the overall services you provided:

______

How many clients are you serving through your food program on a monthly basis? Please explain.

______

Please explain your Board of Directors’ role in the program: ______

(Please attach a separate page, on organization letterhead, with the current Board of Directors with names, addresses, phone numbers, term begin and end dates and Board position for each member).

How often does your Board meet? Monthly/ Quarterly/ Twice a year / once per year

(Please circle the appropriate response)

What are the primary funding sources for your hunger-relief program? (lease explain)

______

What geographic area (s) does your program serve? (Please be specific).

______

How long has your program been functioning?

______

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Do you advertise or have a sign posted? (Please explain)

______

How frequently can clients access your services?

______

Do you take referrals? ___Yes ___ No If yes, from which social organizations?

______

Do you conduct fund raising or special events? (Please tell us about your efforts)

______

Please describe your eligibility or screening criteria and how often and how much food is given:

(Attach any copies of forms the program uses for screening)

______

Does your program keep records of people or meals served? (Please explain)

______

Where do you currently get the food used by your program from? Do you conduct food drives or purchase? (Please explain)

______

Are fees charged for food? If yes, please explain:

______

What days/hours are you open to help people?

Days Hours

Monday ______

Thursday ______

Tuesday ______

Friday ______

Wednesday ______

Saturday ______

Sunday ______

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Who determines when the program should be open? (Please explain)

______

Does your program provide assistance with hygiene or over the counter medication? Are there any other services your agency provides? If yes, please explain:

______

Do you have internet access at your organization? ___Yes ___ No

If “No,” do you have access to internet regularly through another medium? ___Yes ___ No

Could you use an internet-based computer program for entering client information at the time of distribution? ___Yes ___ No

What other information should we know about your program?

______

______

______

SECTION IV: Reference (to be completed by all applicants)

Please provide the name of one social service agency or church in your neighborhood that is familiar with your program:

Name of Agency: ______

Name of Contact: ______

Address: ______

Telephone Number: ______

Section V: CONTACT INFO SUMMARY

Primary Contact for Partner Agency:

Name ______Title______# ______

Name of person filing application______

Position______Date______

How did you hear about Food Bank of the Albemarle? ______

______

Please note: Completion of this application does NOT guarantee membership. We reserve the right to refuse membership to programs not meeting our criteria. Applications may be put on a waiting list if there are no membership openings available at the time.

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What’s Next?

After an organization is accepted for partnership with Food Bank of the Albemarle, there are a few additional steps before you can start ordering food:

  1. Attend an Agency Orientation here at Food Bank of the Albemarle, a training that the Director and ideally the Board President and 1-2 other volunteers would also attend. Anyone who will need to be authorized to sign the invoice for a food order needs to attend this training.
  2. A Food Bank of the Albemarle staff member needs to visit your facility and review for food safety, sanitation, database accessibility, and record keeping abilities.
  3. Pay the annual membership fee (prorated since the fee is billed in January)

Please talk with the Agency Relations Manager at (252) 335-4035 x108 for questions.

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