Application for Registration as an Agency – Western District Food Share

AGENCY CONTACT INFORMATION

Agency / School Name

ABN Number (if applicable)

Key Contact

Title

Mobile

Agency CEO / GEM

Contact Phone Number

Agency Street Address

Street Address City State / Province / Region ZIP / Postal Code

Agency Postal Address

Street Address City State / Province / Region ZIP / Postal Code

ORGANISATIONAL STRUCTURE

Is your Agency a Not-For-Profit organisation?

Yes

Is your Agency part of/auspiced by a larger organisation?

Yes

Is your organisation a school? (If yes, go to Section 4)

Yes

Does your organisation have deductible gift recipient status with the Australian Taxation Office?

Yes

AGENCY PROGRAM/CLIENT PROFILE

a) In regard to food, on a weekly basis, approximately how many individuals is your organisation assisting with emergency relief?

1 to 50

51 to 100

101 plus

b) Do you provide emergency food relief to your clients? (If yes, go to c)

Yes

(Emergency relief is the provision of critical support to individuals and families experiencing a financial emergency or crisis.)

c) What sort of emergency relief service/program does your organisation provide?

Meals program (community kitchen, food van, etc)

Yes

Food Parcels (pre-packed)

Yes

Food vouchers

Yes

Other (please specify)

Do your clients have to meet specific criteria to access your emergency relief?

Yes

Please specify(Required)

Describe your anticipated requirements for food/other aid from Western District Food Share

AGENCY DOCUMENTATION

Evidence of Public Liability Insurance (please attach)

Max. file size: 128 MB.

ATO documentation certifying DGR Status (IF APPLICABLE)

Max. file size: 128 MB.

Please advise if you have a Food Safety Plan in place

Yes

If yes please upload document

Max. file size: 128 MB.

Name of a Referee to support your application:

Name of referee

Position

Organization Name

Contact Number

AGENCY DISTRIBUTION AGREEMENT

At Food Share we distribute food to agencies and schools who provide that food to individuals and families who find themselves in a position of financial difficulty and experiencing food insecurity.
Food insecurity occurs when people lack secure access to sufficient amounts of safe and nutritious food for normal growth and development and active and healthy life.
A person is seen to be in a position of financial difficulty if they don’t have enough financial resources to have a modest standard of living in Australia. Agencies are best placed to assess the indicators of financial difficulty.
By signing and submitting this application, you agree that:
– you will only provide food received from Western District Food Share to your clients on the condition that they are experiencing food insecurity/financial difficulty.
– we may ask you at any time for evidence that your clients to whom you provide the food meet this requirement.
– emergency food relief will be provided to your clients at no charge.

Name of person applying

Date(Required)

Position