Agency Application

Organization/Employer

Name of the Main Contact

First Last

Business Name

Contact Information

Address of the organization your applying for

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

County(ies) served

Contact Email

Contact Phone Number

Can this phone receive text messages?

Yes

No

Name of person that is responsible for picking up donations (if different than above)

Are you a 501c3, church, school, or similar organization?(Required)

Yes

No

Please upload a copy of your 501c3 IRS designation letter

Max. file size: 300 MB.

EIN

What is your annual operating budget for the current year?(Required)

Is your organization operating under the umbrella of another 501c3 or church?(Required)

Yes

No

Upload a letter of support from that organization on their letterhead.

Please make sure there is contact information for the Director/Key Staff of that organization listed on the letter.

Max. file size: 300 MB.

It's time to pause.

If you are not a 501c3, church, or school and you do not have a qualified partner, we are not ready to move forward just yet. You will need to find a community partner to work with in order to receive food from Potluck Food Rescue. If you have any questions, please reach out to our director Sylvia Blain at sblain@potluckfoodrescue.org or call the office @ 501-371-0303.

Capacity and Storage

Provide information on what kitchen equipment your agency currently has on-site

Tell us about your kitchen and/or food storage area

How do you store frozen items? How do you store refrigerated items? Do you have commercial storage space or residential appliances? Do you cook on site?

Can you pick up food from Potluck between the hours of 9am and noon on your assigned day?

Yes

No

What type of vehicle(s) will you use to pick up your donation?

This helps us determine the maximum size of your donation. This does not mean we will be able to fill each vehicle to capacity.

Let us know any other important information here.

MAILING ADDRESS

PLEASE NOTE