County - IN  Click to Select Daviess Dubois Gibson Perry Pike Posey Spencer Vanderburgh Warrick     County - IL   Click to Select Alexander Edwards Gallatin Hamilton Hardin Johnson Lawrence Massac Pope Pulaski Richland Saline Union Wabash Wayne White     County- KY    Click to Select Crittenden Daviess Henderson Hopkins Livingston McLean Union Webster

Agency Name:   

Agency Site Address:   

  City:     Zip:     

Agency Mailing Address (If different):   

  City:     Zip: 

Name of Principal officer: 

 Phone:      Fax:     Email Address:   

Name of Primary Contact: 

 Phone:      Fax:     Email Address:   

Best Time to Contact:   

Do you have refrigeration? Yes    No

Do you have a freezer? Yes    No

Do you have adequate pallets, tables, or shelves to store dry goods away from the floor? Yes    No

TYPE OF OPERATION

Emergency Food - Food Pantry

Average Number of Household Served:   Average Number of People Served:

Soup Kitchens/Shelter Operations

    Average Number of Meals Served:    Average Number of People Served:

On-Site/Residential Programs

    Average Number of Meals Served:    Averge Number of People Served:

Programs:

Are you interested in starting a:    Kids Cafe:      (Click to Select) YES NO

                                                Back-Pack Program: (Click to Select) YES NO

                                                USDA Commodities Distribution: (Click to Select) YES NO

Does someone on your staff have a Food Handlers Certification? (Click to Select) YES NO

If no, would you be interested in a group training and certification session?  (Click to Select) YES NO

Hours Of Operation

Sun Hrs:  Frequency (Click to Select) WEEKLY BI-WEEKLY MONTHLY (If bi-weekly or monthly selected, check each that apply)

                                                                                        1st week of mo.2nd week of mo. 3rd week of mo.4th week of mo.

Mon Hrs:  Frequency (Click to Select) WEEKLY BI-WEEKLY MONTHLY (If bi-weekly or monthly selected, check each that apply)

                                                                                         1st week of mo.2nd week of mo. 3rd week of mo.4th week of mo.

Tue Hrs:  Frequency (Click to Select) WEEKLY BI-WEEKLY MONTHLY (If bi-weekly or monthly selected, check each that apply)

                                                                       1st week of mo.2nd week of mo. 3rd week of mo.4th week of mo.

Wed Hrs:  Frequency (Click to Select) WEEKLY BI-WEEKLY MONTHLY (If bi-weekly or monthly selected, check each that apply)

                                                                       1st week of mo.2nd week of mo. 3rd week of mo.4th week of mo.

Thu Hrs:  Frequency (Click to Select) WEEKLY BI-WEEKLY MONTHLY (If bi-weekly or monthly selected, check each that apply)

                                                                       1st week of mo.2nd week of mo. 3rd week of mo.4th week of mo.

Fri  Hrs:  Frequency (Click to Select) WEEKLY BI-WEEKLY MONTHLY (If bi-weekly or monthly selected, check each that apply)

                                                                       1st week of mo.2nd week of mo. 3rd week of mo.4th week of mo.

Sat Hrs: Frequency  (Click to Select) WEEKLY BI-WEEKLY MONTHLY (If bi-weekly or monthly selected, check each that apply)

                                                                                        1st week of mo.2nd week of mo. 3rd week of mo.4th week of mo.

Do you agree to the following:

1. You will provide transportation to pick up food from the TSFB (Rural areas may apply for delivery based on availability):    Yes    No

2.   You will provide food to clients/recipients at NO COST, implied or perceived.  Including monetary, volunteer services, and/or gifts-in-kind.  This applies to on-site meals, as well as, food packages.    Yes       No

3. You will provide food storage appropriate for products provided:    Yes       No

   You will adhere to any donor restrictions upon disbursement of food.    Yes       No

4. You will operate in accordance with state statues and local ordinances.     Yes       No

5. You will provide a copy of your organization's 501(c)3.    Yes       No

6. You will provide a signed Member Agency Agreement contract:    Yes      No

7. Your will provide a certificate of good standing from your sponsor when requested.      Yes       No

8. You will remit to TSFB shared maintenance fee in accordance with the terms of the invoice.    Yes       No

9. You will complete and submit the required Monthly Report to TSFB by the 15th of each month.    Yes       No

10. You will allow monitoring visits and inspections by TSFB, America's Second Harvest, and the Department of Health.    Yes       No

11. Your will provide any product you receive from TSFB with no cost to the recipients.    Yes       No

12. You will duly inspect and distribute products from TSFB only if product is found to be fit for human consumption.    Yes       No

13. Food from TSFB is accepted "As Is"     Yes       No

14. There have been no express or implied warranties made in relation to the received food.    Yes       No

15. TSFB and the original donor expressly disclaim all warranties including any implied warranties or the merchantability or fitness of the received product.      Yes       No

16. TSFB and the original donor are released by the recipient agency from any liability resulting from the condition of received product, and further TSFB and the original donor are indemnified and held free and harmless against any and all liabilities, damages, losses, and/or claims whatsoever arising out of or attributed to any action of said agency, or personnel employed by said agency, in connection with the storage or use of the received product, and that it will not sell or offer for sale received product.    Yes       No

17. Your will be certified and approved by all pertinent health and governmental organizations.     Yes       No

18. Your will provide product only for the ill, the needy, or infants:    Yes       No

19. you will not deny access to donated product on the basis of race, creed, national origin, religious applications, sex, sexual preference, age, or handicap.    Yes       No

20. You will not allow Tri-State Food Bank's  name to be used in fund solicitation or public relation releases without explicit written authorization.    Yes  No

COMMENTS:

Typed name of person completing this form

Signature of person completing this form    Date

Phone number for person completing this form

Please attach the following:

PCopy of 501(c)3 - Refer to Agency Eligibility Checklist

PList of Board of Directors

PMission Statement

E-mail this application and attachments to jhillenbrand@tristatefoodbank.org

Or

Fax to (812) 425-0776

or hit submit for quicker processing and mail attachments.