Step 1 of 8

I. Organization Information

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I. Organization Information

Date

Name of Organization

Telephone of Organization

Mailing/Billing Address of Organization

Street Address City State / Province / Region ZIP / Postal Code

Submit separate listing of all storage and food distribution addresses, if more than one location.

Address of Food Storage/Distribution Facility

Street Address City State / Province / Region ZIP / Postal Code

Do you have any additional storage and food distribution locations?

Address of Food Storage/Distribution Facility

Street Address City State / Province / Region ZIP / Postal Code Country

Address of Food Storage/Distribution Facility

Street Address City State / Province / Region ZIP / Postal Code

Address of Food Storage/Distribution Facility

Street Address City State / Province / Region ZIP / Postal Code

Address of Food Storage/Distribution Facility

Street Address City State / Province / Region ZIP / Postal Code

Address of Food Storage/Distribution Facility

Street Address City State / Province / Region ZIP / Postal Code

Director Name

Director Phone

Director Email

Federal Employer Identification Number

Liability Insurance Carrier

How long has your organization been in operation?

Have you been a past FBR Partner Agency?

Yes

If yes, list year(s) of past Partnership

Is your organization an affiliate of a larger organization?

Yes

If yes, list name of this organization.

If yes, list address of this organization.

Street Address City State / Province / Region ZIP / Postal Code

Does your organization possess a 501(c)3/Public Charity Status?

Yes

If yes, submit copy of IRS Determination letter with application. (REQUIRED IF YOU ANSWERED "YES" TO THE ABOVE QUESTION)

Drop files here or

Max. file size: 50 MB.

Your attachment should look like this example. Please note, this is not your sales tax exempt certificate. You will be asked to attach that later in this application.

II. Key & Authorized Personnel

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II. Key & Authorized Personnel

Food Program Contact Name

Food Program Contact Phone

Food Program Contact Email

Is This Also The Contact For Billing?

Billing Contact Name

Billing Contact Phone

Billing Contact Email

Food Pickup & Ordering Authorization

List up to 4 people who are authorized to pick up & order food product from Food Bank of the Rockies on behalf of your organization:

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Food Pickup & Ordering Authorization

1st authorized shopper

Name

Phone

2nd authorized shopper

Name

Phone

3rd authorized shopper

Name

Phone

4th authorized shopper

Name

Phone

Would you like to add additional authorized shoppers?

Name

Authorization Type

Phone

Name

Authorization Type

Phone

Name

Authorization Type

Phone

Name

Authorization Type

Phone

How many staff/volunteers help you operate your food program?

Staff

Volunteers

Staff total weekly hours

Volunteers total weekly hours

Does your organization have an active board?

Yes

If yes, how often do they hold board meetings?

Please submit a list of Board Members and contact information, if a Board exists.

Drop files here or

Max. file size: 50 MB.

VII. Food Pantry Program

Are clients receiving food products to take home for preparation and consumption? If yes, please complete this section. Otherwise, leave blank.

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VII. Food Pantry Program

Are clients receiving or will they receive food products to take home for preparation and consumption?

1. How long has the food pantry program been in operation?

2. Which days and hours will clients be able to receive food?

Sunday

Morning

Afternoon

Evening

Frequency

Monday

Morning

Afternoon

Evening

Frequency

Tuesday

Morning

Afternoon

Evening

Frequency

Wednesday

Morning

Afternoon

Evening

Frequency

Thursday

Morning

Afternoon

Evening

Frequency

Friday

Morning

Afternoon

Evening

Frequency

Saturday

Morning

Afternoon

Evening

Frequency

3. How many unduplicated households will be served monthly?

How many unduplicated individuals will be served monthly?

Example: Household “A” visits your food pantry every Thursday. Household “A” is only counted one time for the month. Count the number of people in each unique household to report unduplicated individuals.

4. How often can an individual access your food pantry?

5. Are the food boxes only a seasonal/holiday distribution?

Yes

If yes, list holidays or seasons:

Example: Summer camps, snacks at community festivals | Thanksgiving outreach, Holiday meals

6. What is most true about your distribution method? Check all that apply.

Client Choice - (Clients are able to choose ALL items they receive)

Preassembled Boxes – (Clients are handed a box/bag of pre-packed food products – no choice or ability to express dietary needs)

Mix of Client Choice/Preassembled Boxes – (A combination of both styles)

Other Method

If other, please provide information

I. Organization Information

II. Key & Authorized Personnel

Food Pickup & Ordering Authorization

III. Organization Services & Client Information

Outreach & Media

IV. Finances

V. Food Storage Location & Transportation

VI. On Site Food Program

VII. Food Pantry Program

VIII. To Be Completed By All Applicants

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