Agency Application for Second Harvest Food Bank of Middle Tennessee

Transcription

1 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. Shopping List Sent To: Phone No. Address: Direct Monthly Statements To: Phone No. Agency fax number: Address: Days and Hours of operation: Maximum serving capacity: Second Harvest program applying for: Community Food Partner Nashville s Table Please indicate which description fits your program (check all that apply): 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 1990) A current copy of the Food Service Training Certificate from the local Health Department or UT Extension (if meals are prepared and served on-site or Nashville s Table applicant) $25 non refundable application fee (if not currently Community Food Partner or Nashville s Table Agency) 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: 1

2 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 Indicate what county/counties you serve: Davidson County Rutherford County Williamson County Other counties (please list): How would you describe the people your program serves? Eligibility requirement: Program goals: IF YOU SERVE MEALS: FOOD SERVICES 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 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 church) IF YOU OPERATE A CHILD CARE PROGRAM: Please send a copy of current state license Number of children licensed: Number currently enrolled: Program includes: Infants (Please check all Pre-School Children 2

3 that are applicable) 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 receive from Second Harvest Food Bank. If client fees are used in your program, please explain. 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: NASHVILLE S TABLE DELIVERY ARRANGEMENTS Location where Nashville s Table food should be delivered (back entrance, etc.) and special instructions: AGREEMENT for COMMUNITY FOOD PARTNERS Only the following individuals are authorized to pick-up your food order. 3

4 As the authorized representative(s) for the private, non-profit organization named below, I understand Second Harvest Food Bank will donate 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 2. 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. (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 3. The organization will pay the warehouse $.18 per pound shared maintenance fee on all donated items and co-op fees as indicated received from the Second Harvest Food Bank. The Rural Delivery Program has a delivery charge of $.004 (four cents) per pound of food delivered with a maximum delivery charge of $ Initial 4. Organizational check only. No cash, personal checks, or money orders. Initial 5. 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 6. The organization will accept all products in as is condition. Initial 7. 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 8. 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 9. The organization releases the original donor, the food bank and America's Second Harvest from any liabilities resulting from the donated products. Initial 10. 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 America's Second Harvest. Initial Signature of Authorized Representative: Name of Organization: Date: AGREEMENT for NASHVILLE S TABLE PARTICIPANTS For Nashville's Table partner agencies only 4

5 As the authorized representative(s) for the private, non-profit organization named below, I understand Second Harvest Food Bank of Middle Tennessee, Inc. will donate 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 2. The organization will utilize employees with sufficient training and experience to insure the integrity and palatability of all food items from the Second Harvest Food Bank. Initial 3. 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 4. 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 5. 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 6. The organization must provide personnel to help unload deliveries from our delivery vehicles. If assistance is not available, donations will not be delivered to the agency. Initial 7. The organization understands that we cannot guarantee a specific delivery time. Deliveries are transacted between 10:00 AM and 3:00 PM. Initial 8. The organization understands that any hold on the account will last a minimum of 60 days. Initial 9. 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. (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 10. The organization releases the original donor, Second Harvest Food Bank of Middle Tennessee, Inc. and America's Second Harvest from any liabilities resulting from the donated products. Initial Signature of Authorized Representative: Name of Organization: Date: 5