Question Title

* 1. What is your name?

Question Title

* 2. What is the name of the organization or business where this will take place?

Question Title

* 3. Full address of location where meals will be distributed: (address, city, state, zip)

Question Title

* 4. Site phone number:

Question Title

* 5. Who will be the main contact for this site?

Question Title

* 6. Contacts email?

Question Title

* 7. Main contacts title?

Question Title

* 8. Has the above person participated in SFSP more than 2 years?

Question Title

* 9. Who will be the site supervisor for the above location?

(Site supervisor is defined as the individual on site for the duration of the meal service, who has been trained by the sponsor and is responsible for all administrative and management activities at the site)

Question Title

* 10. What will be the Operation Start Date?

Date

Question Title

* 11. What will be the Operation End Date

Date

Question Title

* 12. Which meal type(s) will be served at this site? (Select up to 2)

Question Title

* 13. What time will the first meal be distributed?

Question Title

* 14. If serving a second meal, what time will it be served?

Question Title

* 15. What days will you be distributed?

Question Title

* 16. What type of meal site will you operate?

Question Title

* 17. How many children do you anticipate serving? (This can be changed at any time, we need a ballpark number to get the program started).

Question Title

* 18. Are there any days that you know that you will not be distributing meal? (i.e. - Fourth of July)

Question Title

* 19. What will your distribution look like?

Question Title

* 20. Will there be any meal time exceptions? If so, what?

Question Title

* 21. How do you plan on keeping count of how many meals served each day?

Question Title

* 22. Describe how your organization will deliver and hold meals until the time of meal service.

Question Title

* 23. How will you or how have you advertised for SUN (summer meals)?

Question Title

* 24. I hereby certify that neither the Organization nor its principals/authorized representatives is presently debarred, suspended, proposed for debarment, declared ineligible, disqualified, or voluntarily excluded from participation in this transaction by any Federal/State department or agency.

I certify under penalty of perjury that the information on these application forms is true and correct, and that I will immediately report to the State any changes that occur to the information submitted.
I understand that this information is being given in connection with receipt of federal funds. The State may verify information; and the deliberate misrepresentation of information will subject me to prosecution under applicable federal and state criminal statutes.

On behalf of the Organization, I hereby agree to comply with all state and federal laws and regulations governing the School and Nutrition programs administered by the State. In accordance with Federal law and U.S. Department of Agriculture policy, this Organization does not discriminate on the basis of race, color, national origin, sex, age or disability. I will ensure that all monthly claims for reimbursement are true and correct and that records are available to support these claims.

**By initialing the box, you understand the above statement

Question Title

* 25. This information will be used to submit an online application to IowaCNP’s
website, in which is ran by the Department of Education to determine eligibility and reimbursement purposes. This application is not deemed as a partnership until the application is approved by the state representative and the Children’s Programs Manager at the Northeast Iowa Food Bank.

*By initialing, you acknowledge that you understand the above statement