Prospective Agency Request for Membership Form (April 2018-March 2019)

Prospective Agency Request for Partnership Interest Form
Please Note- Feeding Tampa Bay reviews prospective agency interest forms twice per year, in March and August.

Interest forms submitted March 1st 2019- July 31st 2019 will be reviewed in August 2019.

A member of the Feeding Tampa Bay Agency Relations staff will contact your organziation via email when the review process has started.
Today's Date *

- Month - Day Year
Contact Person *

First Name Last Name
Phone Number *

- Area Code Phone Number
E-mail *
Name of Organization *

Organization Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Food Storage/ Distribution Site Address (If different from above)

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

What county is your Feeding Program in? *

Hillsborough Pinellas Pasco Hernando Sumter Citrus Polk Hardee Highlands
What type of organization are you? *

Church Ministry Outreach Shelter
Does your organization have a 501(c)3? *

Yes No
Does your organization have a Consumer's Certificate of Exemption (Florida State Tax Exempt Certificate)? *

Yes No
Do you currently operate a food distribution or feeding program? *

Yes No
What type of program do you operate or plan to operate? Check all that apply *

Emergency Pantry/Food Box Soup Kitchen Emergency Shelter Residential Center Rehab Center Senior Youth Program Multi-Service
Please describe your organization and its mission *
Please describe your organization's food program, if applicable
Where does your organization currently receive food from?
How often is your organization distributing food? *

Daily Weekly Bi-Weekly Monthy N/A
What day/s are you currently distributing to the community?
Ex- Every Tuesday or the 4th Friday of the month
What time(s) are you currently distributing to the community?
Ex- 9:00-11:00 am
How many households/ families do you currently serve per month? *
How many households/ families would you have the ability to serve per month if you had more food resources available? *
How many regular volunteers does your organization have to assist with your distribution? *
What type of transportation do you have to pickup food? *

Car Van Pickup Truck Cargo Van Box Truck Refrigerated Truck
How many refrigerators do you have? *
What type of refrigeration do you have? *

Standup Refrigerator Chest/Reach in Cooler Refrigerator/Freezer Combo Walk in Cooler None
How many freezers do you have? *
What type of freezer space do you have? *

Standup Freezer Chest/Reach in Freezer Walk in Freezer None
What other services, if any, does your organization offer? *

Clothing Personal Care/Hygiene Items SNAP/Food Stamp Application Assistance Utility/Rent Assistance
Additional Comments
This institution is an equal opportunity provider.
Should be Empty:

Prospective Agency Request for Partnership Interest Form