<p> 800 Tidewater Drive Norfolk, VA 23504 757-627-6599 757-627-8588 FAX</p><p>Partner Agency Application Form</p><p>SECTION 1: GENERAL INFORMATION</p><p>Date: ______Email: ______</p><p>Organization’s Name: ______</p><p>Site Address: ______Site Phone: ______</p><p>Mailing Address: ______</p><p>Contact Person: ______Contact Phone: ______</p><p>Contact Person’s Address:______</p><p>Contact Person’s Email:______</p><p>Parent and/or Affiliate Organization: ______</p><p>Authorized Shoppers (Persons authorized to order and pick up food):</p><p>(1) Name: ______Phone: ______</p><p>Address: ______</p><p>Email Address: ______</p><p>(2) Name: ______Phone: ______</p><p>Address: ______</p><p>Email Address: ______</p><p>(3) Name: ______Phone: ______</p><p>Address: ______</p><p>Email Address: ______</p><p>Do you have a FEDERAL non-profit determination status under Section 501(c)3 of the IRS code? ( ) YES ( ) NO If YES, what is</p><p> your Employer Identification Number (EIN) or Tax Identification Number (TIN)? ______Foodbank Verified ( )</p><p>What are your sources of funding? ______</p><p>What is your monthly budget for your food program?______</p><p>* There is a $100 annual membership fee (AMF) that is due upon approval of your site inspection and is also billed on your anniversary date every year thereafter. Further, all new and reactivated agencies will be required to carry a credit balance on your account in order to access product from the Foodbank. The minimum initial deposit required is $100. The $100 AMF and your deposit are both due upon approval of your application.</p><p>Revised 12/08/16 AS Please describe your general program including when you started providing services (or attach agency brochure):</p><p>SECTION II: FEEDING PROGRAM INFORMATION</p><p>As a partner agency of the Foodbank, your agency is required to be open to serve those in need at least once per month.</p><p>FIELDS OF SERVICE (check all that apply)</p><p>( A ) Emergency / Supplemental Food Pantry</p><p>______Emergency food packages (providing food to those in need of one-time or short-term food assistance)</p><p>______Supplemental food packages (providing food on more of a regular basis to help supplement what person already has)</p><p>( B ) Residential Program (cooking and serving meals to a registered clientele)</p><p>______Day Camps (Children) ______Residential Camps</p><p>______Family Day Care (Children OR Adults) ______Day Care Center (Adults, elderly, disabled, or mentally handicapped)</p><p>______Developmental experiences for disabled children & adults</p><p>______Group care or living for the aged and chronically ill ______Group care or living for troubled youth or adults</p><p>______Shelter programs</p><p>______Drug / Alcohol Rehabilitation</p><p>( C ) Soup Kitchen (cooking and serving meals to walk-in clients on a regular or occasional basis)</p><p>______Soup Kitchen ______Snacks Only </p><p>*DEPENDING ON WHAT FIELDS YOU CHECKED, PLEASE COMPLETE THE FOLLOWING</p><p>( A ) Emergency/Supplemental Food Pantry</p><p>1. What days and hours is your pantry open to help people?</p><p>Days: Sunday Monday Tuesday Wednesday Thursday Friday Saturday</p><p>Hours:</p><p>2. Approximately how many households per month are you now serving? ______</p><p>3. What foods to you plan to provide (check appropriate food)? ___canned goods ___frozen foods ___dry goods (rice, cereal, etc.) ___perishables (dairy, fresh fruit, etc.) ___ meats (fresh/frozen)</p><p>4. How many days supply of food for each household is provided?______</p><p>5. What are your eligibility guidelines? How often may a person receive food? ______</p><p>6. How many refrigerators and freezers do you have? Enter below.</p><p>Revised 12/08/16 AS How many? Total cubic feet? Refrigerators: Freezers:</p><p>7. Present sources of food: % donated ______% purchased______</p><p>8. Do you accept walk-ins? ( ) YES ( ) NO Do you require referrals? ( ) YES ( ) NO </p><p>If you require referrals, from which sources?</p><p>______</p><p>9. What contact information should we give to a client needing food assistance when referring them to your agency?</p><p>Name ______Phone Number ______</p><p>10. Do you require people to attend church services or work in exchange for food? ( ) YES ( ) NO </p><p>( B ) Residential/Shelter Programs</p><p>1. How many individuals are in your program?______</p><p>2. What meals do you serve? Breakfast ( ) Lunch ( ) Dinner ( ) Snacks ( )</p><p>3. What days do you serve meals? Sun ( ) Mon ( ) Tues ( ) Weds ( ) Thurs ( ) Fri ( ) Sat ( )</p><p>4. How many refrigerators and freezers do you have? Enter below.</p><p>How many? Total cubic feet? Refrigerators: Freezers:</p><p>5. Do you charge for meals? ( ) YES ( ) NO </p><p>6. Do you have a health certificate from the local board of health licensing you to serve public meals? ( ) YES ( ) NO </p><p>Certificate #: ______Please attach a copy to this application.</p><p>7. What percentage of your clients are low-income and/or eligible for government aid?______</p><p>8. Present sources of food: % donated ______% purchased______</p><p>9. Name of person(s) in charge of food preparation: ______</p><p>Does he or she have their food manager’s/handler’s card? ( ) YES ( ) NO</p><p>10. Are any of your meals catered? ______If so, by whom? ______</p><p>( C ) Soup Kitchens</p><p>1. How many individuals are served per meal? ______What ages? ______</p><p>Revised 12/08/16 AS 2. Which meals do you serve? Breakfast ( ) Lunch ( ) Dinner ( ) Snacks ( )</p><p>3. What days and hours do you serve meals?</p><p>Days: Sunday Monday Tuesday Wednesday Thursday Friday Saturday</p><p>Hours:</p><p>4. Do you charge for meals? ______If yes, how much? ______</p><p>5. Name of person(s) in charge of food preparation: ______</p><p>Does he or she have their food manager’s/handler’s card? ( ) YES ( ) NO</p><p>6. Do you have a health certificate from the local board of health licensing you to serve public meals? ( ) YES ( ) NO </p><p>Certificate #: ______Please attach a copy to this application.</p><p>7. Present sources of food: % donated ______% purchased______</p><p>8. How many refrigerators and freezers do you have? Enter below.</p><p>How many? Total cubic feet? Refrigerators: Freezers:</p><p>SECTION III (TO BE COMPLETED BY ALL APPLICANTS) </p><p>1. Name of person filling out application______Position: ______</p><p>2. How did you hear about The Foodbank of Southeastern Virginia? ______</p><p>3. How often do you anticipate accessing food products from the Foodbank?</p><p>Weekly ( ) Bi-weekly ( ) Monthly ( ) Bi-monthly ( ) Occasional/seasonal ( )</p><p>Agency Contact Person’s Signature: ______</p><p>Please Print Name: ______Date: ______</p><p>Agency Pastor or Executive Director’s Signature: ______</p><p>Please Print Name: ______Date: ______</p><p>PLEASE STOP HERE. The remaining portion to be completed at your initial site inspection.</p><p>SECTION IV FOODBANK USE ONLY- INITIAL INSPECTION</p><p>INITIAL INSPECTION DATE ______FOODBANK REPRESENTATIVE’S NAME______</p><p>Revised 12/08/16 AS 1. ______Food is stored off the floor on shelves or pallets</p><p>2. ______There is no evidence of insects or rodents in food storage area </p><p>3. ______Agency regularly checks grain, rice, nuts, seeds, spices, etc. for signs of pests</p><p>4. ______Does Agency exterminate? If yes, how often? ______</p><p>5. ______Food storage area is clean and well kept</p><p>6. ______Food is stored separately from cleaning supplies</p><p>7. ______Food is stored at least 4 inches off of the ground</p><p>8. ______Refrigerator and freezer are clean and well maintained</p><p>9. ______Are there thermometers in each separate freezer and refrigerator? If no, what does not have a </p><p> thermometer?______</p><p>10. ______Refrigerator is 32-40 degrees </p><p>11. ______Freezer is at or below 0 degrees. </p><p>12. ______Agency has some routine for checking temperature of cold storage</p><p>13. ______Cold foods are kept cold, dry foods are kept dry</p><p>14. ______No food is stored off site or in someone’s home</p><p>15. ______Agency representatives take food from Foodbank directly to the site for proper storage</p><p>16. ______Agency has made provisions to transport refrigerated/frozen products from Foodbank to agency site</p><p>17. ______Agency uses First In, First Out system</p><p>18. ______Food is kept in a secure area</p><p>19. ______Storage area is dry (free from moisture)</p><p>20. ______There is no evidence of stock piling</p><p>ON SITE FEEDING PROGRAMS ONLY: 1. Are sinks clean and maintained? ( ) YES ( ) NO Comment______</p><p>2. Is stove clean and maintained? ( ) YES ( ) NO Comment______</p><p>3. Are temperature guidelines posted? ( ) YES ( ) NO Comment______</p><p>4. Is the dining area clean? ( ) YES ( ) NO Comment______</p><p>5. Kitchen License? ( ) YES ( ) NO License #______</p><p>Please read and initial each section below:</p><p>Initial Read</p><p>Revised 12/08/16 AS ANY SAFE FOOD HANDLING OVERSIGHTS OR INFRACTIONS WILL RESULT IN A 30 DAY PROBATION PERIOD. Agencies may draw Foodbank product during this 30 day period with the understanding that they will implement any safe food handling techniques found missing. At the end of 30 days, a Foodbank representative will return for an on-site visit. If no infractions in safe food handling are found, the probation period will be lifted. IF SAFE FOOD HANDLING IS STILL NOT OBSERVED, THE AGENCY WILL BE PLACED ON 30 DAYS SUSPENSION. Agencies may not draw any Foodbank product during the period of suspension. During the suspension period, the agency should make any changes necessary to stay in compliance with safe food handling. A Foodbank representative will return for an on-site visit. IF AN AGENCY IS STILL NOT IN COMPLIANCE WITH SAFE FOOD HANDLING GUIDELINES, THE AGENCY WILL BE PLACED ON SUSPENSION UNTIL THEY COME INTO COMPLIANCE. Agencies may not draw any Foodbank product during this period. The agency is responsible for contacting a Foodbank representative to come for an on-site visit.</p><p>General Comments of person interviewed:</p><p>Interviewer’s observations: ______</p><p>______</p><p>Recommendation: ( ) Accept Application ( ) Deny Application</p><p>****( ) Application pending, waiting on ______</p><p>( ) Received pending information, continue with application process.</p><p>Foodbank of Southeastern Virginia Staff Member’s Signature:</p><p>______Date: ______</p><p>Please Print Name: ______</p><p>Sign Here</p><p>Agency Contact’s Signature: ______Date: ______</p><p>Please Print Name: ______</p><p>Revised 12/08/16 AS</p>