State of Arkansas s1

STATE OF ARKANSAS

FOOD SERVICE MANAGEMENT COMPANY (FSMC)

APPLICATION FOR REGISTRATION

2015-2016

COMPANY IDENTIFICATION

1. Legal company name and address (street, city, state and zip code)

Is the company a minority-owned enterprise? Yes No

2. FSMC Contact Information

FSMC Name:

Contact Person (s):

Mailing Address:

Telephone Number: Fax Number:

E-Mail:

CORPORATE PROFILE

3. Is the company incorporated? Yes No

If yes, what month, year and state incorporated in?

Month Year State

4. Does the company pay taxes in Arkansas? Yes No

If yes, what type (i.e. income, sales, etc.)

5. List other names the company is presently using or has used in the past twenty-four (24) months.

6. Is the FSMC currently providing or has the FSMC ever provided meals to the following programs (in Arkansas or other states)?

National School Lunch Program (NSLP) Yes No

Number of NSLP

School Breakfast Program (SBP) Yes No

Number of SBP

Child Care Food Programs Yes No

Adult Care Food Programs Yes No

Summer Food Service Programs Yes No

If yes, and if in Arkansas, complete the next section. Use additional pages if needed.

Program / LEA or Sponsor Name / Address / Phone

PERSONNEL PROFILE

7. List name and title of individuals from the company authorized to sign contracts.

Name / Title

8. List all individuals who are owners, officers, local area representatives, consultants and any individuals with at least 5 percent financial interest in the FSMC, and provide the following information for each: (Attach additional pages if needed.)

Name / Officer/Title

ADDITIONAL INFORMATION

The following information will be used by the Local Education Agency (LEA) when soliciting quotes or bids.

9. The company is currently providing service to LEA(s) in the following counties (check all that apply):

Arkansas County / Ashley County / Baxter County
Benton County / Boone County / Bradley County
Calhoun County / Carroll County / Chicot County
Clark County / Clay County / Cleburne County
Cleveland County / Columbia County / Conway County
Craighead County / Crawford County / Crittenden County
Cross County / Dallas County / Desha County
Drew County / Faulkner County / Franklin County
Fulton County / Garland County / Grant County
Greene County / Hempstead County / Hot Spring County
Howard County / Independence County / Izard County
Jackson County / Jefferson County / Johnson County
Lafayette County / Lawrence County / Lee County
Lincoln County / Little River County / Logan County
Lonoke County / Madison County / Marion County
Miller County / Mississippi County / Monroe County
Montgomery County / Nevada County / Newton County
Ouachita County / Perry County / Phillips County
Pike County / Poinsett County / Polk County
Pope County / Prairie County / Pulaski County
Randolph County / Saline County / Scott County
Searcy County / Sebastian County / Sevier County
Sharp County / St. Francis County / Stone County
Union County / Van Buren County / Washington County
White County / Woodruff County / Yell County

10. List the names of LEA(s) in Arkansas that have current food service management contracts with the company but DO NOT participate in the National School Lunch Program (Attach additional pages if needed).

Local Education Agency Name / County

11. The FSMC WILL CONSIDER submitting proposals/bids to LEA(s) in the following counties in school year 2015-2016 for procurement of FSMC contract in school year 2016-2017 (check all that apply):

12. List the minimum conditions that must generally be met on a county by county basis (i.e. minimum revenue, minimum number of meals/day, minimum number of schools, etc.) in order for the company to consider submitting a proposal/bid to the LEA: (Attach additional pages if needed.)

County / Conditions
Food Service Management Companies who state they WILL do business in all counties with no minimum conditions will be expected to respond to all LEA requests with a proposal or provide an explanation as to why the FSMC did not submit a proposal.

13. List the names of all LEA(s) in Arkansas that had consulting contracts with the FSMC in the last two years:

Year / Local Education Agency / County

CERTIFICATION

14. Name of person to notify if registration documents are incomplete or incorrect:

Print Name:

Title:

Phone number:

Fax number:

E-Mail:

I CERTIFY that the information supplied on this application is true, complete and correct to the best of my knowledge. Any false statement or misrepresentation may be punishable by law (18 U.S.C. 1001).

15. Name of FSMC Official SUBMITTING registration documents:

Print Name:

Title:

Signature:

Date:

DUE BY September 4, 2015 at 4:30 p.m.

No fax copies.

Email or Mail with original signatures.

MAIL TO: Patricia Winders, MS, RD, LD

Arkansas Department of Education, Child Nutrition Unit

2020 West 3rd Street, Suite 404

Little Rock, AR 72205