Retail Donation Program (RDP) Application

To apply for participation in the Feeding America San Diego (FSD)Retail Donation Program (RDP), please complete, in its entirety, this RDP applicationand submit to FSD via fax (858)768-7438 or email:

Administration

SITE INFORMATION

Agency Name: ______Agency #: ______

Distribution Address: ______

City: ______Zip:______

E-mail: ______Phone: _____Fax: ______

STAFF INFORMATION

Agency Executive Director/CEO/Pastor Name: ______

E-mail: ______Phone: ______Fax: ______

Agency Contact Name: ______Title: ______

E-mail: ______Phone: _____Fax: ______

CURRENT FOOD PROGRAM INFORMATION

Agency operates as an:

Emergency food program (distributes bagged or boxed groceries)

On-site food program (prepares and provides meals on site; including living facilities)

Emergency and on-site food program (both)

Operation Day: / SUN / M / T / W / R / F / SAT / ALL
Operation Time:

# Served Monthly: ______Food Budget: ______Funding Source(s):______

Does your agency currentlypick up from a grocery store unrelated to FSD? (Circle) YesNo

If yes, please list the stores and days of pick-ups(for additional stores, list on a separate page & attach):

Store Name(s) & #’s
Days of Pick-up

Retail Donation Program

PLEASE ANSWER THE FOLLOWING

  1. Has your agency:
  2. Submitted allFSD quarterly reports on time?YesNo
  1. Registered with 211?YesNo
  1. PaidallFSD accounts in full?YesNo
  1. Is your agency:
  2. Equipped with a refrigerator truck?YesNo
  1. Equipped with a freezer blanket?YesNo
  1. Prepared to pick up at least 3x/week?YesNo
  1. Able to pick up from multiple grocery locations?YesNo
  1. Staffed with at least one certified food handler?YesNo

**If yes, please attach a copy to this application

  1. Service Area: (please circle one)

FSD reserves the right to give priority to underserved areas

East CountySouth CountyCentral SDNorth County

  1. Explain distribution plan: ______

______

  1. (Expected) # served with FRP product (perishables) in a typical month: ______
  1. Facility Storage:
  2. Dry/PantryQty of Units: ______Dimensions: ______
  1. RefrigeratorQty of Units: ______Dimensions: ______
  1. FreezerQty of Units: ______Dimensions: ______

Desired store locations:

County Region (North, South, etc) / City / Zip Code
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PART FIVE: Signature

I certify that the information on this completed application is true and accurate to the best of my knowledge. I understand falsified information on this application may be grounds for rejection or termination of my organization’s participation in Feeding America San Diego’s Retail Donation Program (RDP).

FOR THE SPONSORING AGENCY:

______

(Executive Director/CEO/Pastor Signature) (Printed Name)

______

(Title) (Date)

______

(Agency Contact Signature) (Printed Name)

______

(Title) (Date)

FOR OFFICE USE ONLY (Do not complete)

______

(FSDRepresentative Signature) (Printed Name)

______

(Title) (Date)

Date Received / Store Option 1 / Date Assigned / Store Option 2 / Date Assigned

Monitoring Visit Date:______

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