Commodity Assistance Application

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.