Program Application: Health & Wellness
Program Name
*
Program Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Program Manager
*
First Name
Last Name
Program Phone Number
*
Please enter a valid phone number.
Program Email
*
example@example.com
Briefly describe the nature of your program and those you serve.
*
Program Website
Program Social Media
Facebook
Twitter X
Instagram
Other
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Are you a 501(c)(3) non-profit organization?
*
Yes
No
Name of Fiduciary Organization
*
This is the 501(c)(3) non-profit organization affiliated with your program.
Upload a copy of your IRS 501(c)(3) documentation
*
Browse Files
Drag and drop files here
Choose a file
IRS regulations indicate that Foodlink cannot provide donated product to non-501(c)(3) organizations.
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Billing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Billing Contact
*
First Name
Last Name
Billing Phone Number
*
Please enter a valid phone number.
Billing Email
*
example@example.com
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Delivery Information
Are you planning to utilize Foodlink to deliver your orders? A minimum of 10 cases of product are required for delivery. Pickup is available for orders below the delivery minimum.
Yes
No, we plan to pickup our orders
Delivery Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County
*
Please Select
Allegany
Genesee
Livingston
Monroe
Ontario
Orleans
Seneca
Wayne
Wyoming
Yates
Is there room for a tractor trailer at this location?
*
Yes
No
What is your preferred time of delivery?
*
Please Select
9:00 am - 11:00 am
11:00 am - 1:00 pm
1:00 pm - 3:00 pm
Choose your preferred 2-hour delivery window
Name of Delivery Contact
*
First Name
Last Name
Delivery Contact Phone Number
*
Please enter a valid phone number.
Delivery Contact Email
*
example@example.com
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Ordering & Shopping Information
Person(s) authorized to place orders are required to attend Foodlink Shopper Training prior to shopping and placing orders. A Foodlink staff person will reach out to the individuals listed below to register them for an upcoming training.
Primary Order Contact
*
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Program Service Plan
Provide the following information about your program if it is currently in operation or your service plan for a new program that is not yet operating.
Are you currently operating your program?
*
Yes
No
Number of HOUSEHOLDS you are serving or you estimate you will serve per month.
*
Monthly average households served
Number of INDIVIDUALS you are serving or you estimate you will serve per month.
*
Monthly average individuals served
What types of items do you distribute consistently or plan on distributing?
*
Personal care products
Baby food / formula
Diapers
Cleaning supplies
Paper products
Clothing
Other
What is your current or planned service area?
*
Zip codes, school district, county, etc.
How does or will your program advertise its services?
Local newspaper
Flyers / Signs
Website
Social media
211 LifeLine
Other
Do you require appointments?
*
Yes
No
Do you offer home delivery?
*
Yes
No
Explain your home delivery service in more detail.
Describe any additional services offered by your program.
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Program Sustainability & Funding
Explain how you currently or plan to secure funding for your program.
*
List any partners you collaborate with who contribute to the sustainability of your program.
Current or planned number of paid staff
*
Current or planned number of volunteers
*
Explain how your program recruits volunteers.
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Signature Page
By signing your name below, you are confirming that the above information about your program is accurate to the best of your knowledge.
Name
*
First Name
Last Name
Title
*
Date Completed
*
/
Month
/
Day
Year
Signature
*
Submit
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