Partner Agency Membership Application

A form for organizations interested in becoming a new partner agency. This form will give details and contact information to our Agency Relations Coordinator to start the process of welcoming a new partner agency.

River Valley Regional Food Bank Membership Application

Organization Information

MM slash DD slash YYYY
Organization's Mailing Address(Required)
Program's Physical Address (if different from organization address)
Name of Agency/Organization Director(Required)
Director Address(Required)
Name of Contact Person (if different from Director, this will be the person appointed as the point of contact for the RVRFB)(Required)
Contact Address
Name of Food Coordinator (if different from above)
Food Coordinator Address
Billing Contact(Required)
Billing Contact Address(Required)
Parent Organization Contact
Parent Organization Address

Program Information

MM slash DD slash YYYY
Types of Service (check ALL that apply and complete ALL applicable sections below)(Required)
How do Neighbors learn about your service?(Required)

Emergency Food Pantry (provides groceries, cleaning supplies, and personal care items)

Regular Open Days
Regular Opening Time
:
Regular Closing Time
:
Are referrals required?
Are appointments required?
Who should people contact for help?
Which items do you distribute? (Check all that apply)
Are neighbors that receive food... (check all that apply)
What funding sources support your food assistance program? (Select all that apply)

Soup Kitchen/Shelter (cooking or serving meals to walk-in guests on a regular or occasional basis and/or providing temporary, emergency lodging)

Days Meals Are Served
Regular Opening Time
:
Regular Closing Time
:
Which populations does your program primarily serve? (Select all that apply)
Are Any of the Meals Catered?
Do you have a health certificate from the local Department of Health?
Who should people contact for help?
After Hours Emergency Contact
Are neighbors who receive services required to or asked to make donations, attend religious services or work?
What funding sources support your food assistance program? (Select all that apply)

On Site/Residential/Kids Cafe (cooking or serving meals to a registered clientele, e.g., detoxification center, half-way house, group home, day activities program, youth or senior program)

Type of Program (See list above)
Regular Open Days
Regular Opening Time
:
Regular Closing Time
:
Meals Served (check all that apply)

Licenses and Numbers

Are any meals catered?
What funding sources support your food assistance program? (Select all that apply)

Day Care Program (serving meals and or snacks to either children or adults enrolled in day care program)

Type of Program
Regular Open Days
Regular Opening Time
:
Regular Closing Time
:
Meals Served (check all that apply)

Licenses and Numbers

What funding sources support your food assistance program? (Select all that apply)

If any of the above programs are already in operation, please provide the following information. If the program is not yet underway, please indicate anticipated numbers.

Type of Population Served

Physical Facilities Information

Are you able to close, lock, and secure the area where the food and products are stored?

Storage Capacity

Do you have a walk-in...
Do all storage areas meet Arkansas Department of Health Requirements?
Is someone in the organization certified in Food Safety?

Transportation Information

Name of Person Completing Application
Clear Signature
MM slash DD slash YYYY