COMMODITY ASSISTANCE APPLICATION Agencies requesting commodity assistance complete this form and return to: Kyle Petrie Denver Rescue Mission PO Box 5206 Denver, CO 80217 Fax (303) 294-9503 Please include with this form your 501(c)(3) determination letter, brochures, news clippings, or any other information concerning your organization. To avoid delays in processing your application, please answer all questions. Date _____________________ Name of Organization ________________________________________________________ Street Address ______________________________________________________________ City _________________________________ State _________ Zip Code _______________ Mailing Address (if different) _______________________________________________________ City _________________________________ State _________ Zip Code _______________ County _________________________ E-Mail Address ______________________________ Contact Person ________________________________ Title _________________________ Telephone ____________________________ Fax _________________________________
1. Has your organization been declared a nonprofit organization by the federal government? _____Yes
_____No
Please attach a copy certifying same (exempt letter from IRS or 501(c)(3) letter from IRS). 2. Is your organization affiliated with any national, state or local organization or church denomination?
_____Yes
_____No
If so, please list the name and address of same: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
3. Does your organization serve other agencies? _____Yes
_____No
If yes, number served __________. Please list agencies served at the end of this application. 4. When was your organization established? _______________________________________ Who is the Executive Director? _______________________________________________ Please list your organization’s Board of Directors or Board of Trustees (you may write them here or attach a separate sheet of paper): _______________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Please check all sources of funding that your organization receives: _____Donations
_____Fees
_____Funds from your affiliation
_____Grants
_____Fundraisers
_____Other (describe) _________________________
5. Does your organization serve hot meals on its premises? _____Yes
_____No
If yes: Total number of families served monthly: ________________________________________ Total number of people served monthly: _________________________________________ Total number of meals served daily: ____________________________________________ Total number of meals served monthly: _________________________________________ 6. Do you supply: _____Food _____Housing _____Hygiene Items
_____Medical Services
_____Vitamins
_____Clothing (_____% fall/winter _____% spring/summer)
7. Does your organization own or have access to transportation? _____Own _____Access Type:
_____Semi
_____Refrigerated Truck
_____Van
_____Box Van
_____Pickup
_____Other (describe) ________________________________
8. Does your organization own or have access to a forklift and/or pallet jack? Forklift:
_____Own
_____Access
Pallet Jack: _____Own
_____Access
9. Can your organization unload bulk loaded produce from a semi-tractor/trailer? _____Yes
_____No
10. Can your organization assist with shipping costs? _____All
_____Shared
_____None (this will not prevent your receiving commodities)
11. Does your organization have warehouse and/or storage space? _____Yes _____No If yes, number of square feet available: __________________________ Does your organization have a loading dock? _____Yes Number of docks available: _______________________
_____No
Warehouse hours: _________ a.m. to _________ p.m. Circle days: M
T
W
Th
F
Sat
Sun
Location Address: __________________________________________________________ _____On Site
or
Distance from your organization _________________________
12. Does your organization have refrigeration space available? _____Yes If yes: _____Cubic Feet Refrigerated
_____No
_____Cubic Feet Freezer
13. Does your organization charge for services? _____Yes
_____No
14. Does your organization charge any fees to recipients (including storage and/or handling fees)?
_____Yes
_____No
15. Does your organization require a donation in order for recipients to receive services or commodities?
_____Yes
_____No
Please list any specific items your organization is asking for assistance with: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Donee agrees that it will neither offer for sale, sell, transfer, nor barter the products supplied by DRM in exchange for money, other negotiable instruments, or other tangible or intangible goods or services. Donee agrees that no fees of any kind will be paid by the end recipient. Signature ____________________________________________________________ Title ________________________________________________________________ Printed Name ________________________________________________________ Date _________________________________ Denver Rescue Mission donates food and other commodities to nonprofit organizations without regard to national origin, race, creed, sex, religion or disability. If you have any questions regarding this application, please call Kyle Petrie at 303-297-1815.