Partner Name Partner Address City State Zip Code Executive Director / Pastor Phone: Fax: Email: Program Name: Site Name: Address ( PO Address not accepted) City: State: Zip Code: Program Director: Phone: Fax: Email: Service(s) Provided: Emergency Food pantry Emergency Shelter Community Kitchen Community Residential Facility Before and After Care Program Day Care Center Group Homes Rehab Center Transitional Shelter Homeless Drop in Center Do your program have a website? Yes No Website Address Do your program have a computer? Yes No Do your program have internet access? Yes No Do your program prepare meals on site? Yes No Do your program charge a fee to access food or services? Yes No If yes please explain below: DC Sites: Neighborhood MD & VA Sites State & Federal District: Individuals shopping for your program and their affiliation Affiliation Name Affiliation Name Affiliation Name Affiliation Signing below, I attest the information provided on this application is true and correct. Date Signature of program Director: Date Send 1026 2020-04-28
