APPLICATION FOR PARTNER AGENCY MEMBERSHIP
Agency Information
Agency Organization Name *
Your answer
Agency website *
Your answer
Has your agency or any agency affiliated with the 501c3 been a partner agency of America's Second Harvest of the Big Bend in the past? *
If YES - what name was used?
Your answer
If you have a 501 (c)3 - please provide your FEIN # below
Your answer
Organization Director *
Your answer
Phone # *
Your answer
Fax # *
Your answer
E-Mail address *
Your answer
Street *
Mailing Address
Your answer
City *
Mailing Address
Your answer
Zip *
Mailing Address
Your answer
County *
Mailing Address
Your answer
Please list all authorized representatives of the above named Organization who may access product from America’s Second Harvest of the Big Bend. *
Your answer
Contact Information
Name *
Contact Person
Your answer
Position with Organization *
Contact Person
Your answer
Phone # *
Contact Person
Your answer
Street *
Contact Address
Your answer
City *
Contact Address
Your answer
Zip *
Contact Address
Your answer
County *
Contact Address
Your answer
Food Storage Information
Street *
Food storage location
Your answer
City *
Food storage location
Your answer
Zip *
Food storage location
Your answer
County *
Food storage location
Your answer
Is your pantry ADA accessible? *
Food storage location
Is your facility accessible for semi-truck deliveries? *
Food storage location
Food Distribution Information
If different than food storage location.
Street
Food distribution location
Your answer
City
Food storage location
Your answer
Zip
Food storage location
Your answer
County
Food storage location
Your answer
Sponsor Information
(If applicable)
Agency Name
Your answer
City
Your answer
State
Your answer
Director or Pastor
Your answer
Phone #
Your answer
** If you are being sponsored by a 501(c)3 agency, the sponsoring agency must provide written approval on letterhead along with a copy of their 501(c)3 letter of exemption from the Internal Revenue Service **
Your answer
AFFIRMATION
Upon receiving donated food and commodities from America’s Second Harvest of the Big Bend (ASHBB), the above named applicant organization agrees and affirms...
• The organization is an established 501(c)3 charitable organization that serves the ill, poor, and/or needy. (A copy of the letter of determination, or equivalent valid documentation of the14 points from the IRS, must be attached.)
• That this contract is meant to have legal significance and that ASHBB and its donors disclaim any warranties of representations, expressed or implied, as to the purity of fitness for consumption of items drawn from ASHBB.
• That it will accept product it decides to draw from ASHBB "as is."
• That ASHBB and its donors are to be held free and harmless against any and all liabilities, damages, losses, claims, causes of action, and suits of law or inequity or any obligation arising out of any action of said applicant organization or any personnel employed by the said applicant organization in connection with its storage and use of donated product.
• That it will adhere to the policies and procedures, additions, and revisions set by ASHBB.
• That it does not require food recipients to attend worship or prayer services, or ask questions about the recipients’ religious beliefs or practices.
The undersigned hereby agrees that they are authorized agents of the applicant organization, and that their legal signature does bind the applicant organization to the terms, conditions, and limitations of the application agreement.
“This institution is an Equal Opportunity Provider.”
Do you accept these conditions? *
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