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HOUSTON FOOD BANK MEMBERSHIP APPLICATION
Section 1: General Information
***ALL APPLICATIONS MUST INCLUDE A $25.00 NON-REFUNDABLE APPLICATION FEE***
Date___________________________
Name of Agency
Have you ever applied for membership with the Houston Food Bank? Yes No
If so, when? __________________________________________________________________
Physical Address (if more than one site, include all sites)
Mailing Address (if different from physical address)
County
Pastor of Church or President of Board (whichever is applicable):
Name________________________________________ Phone
Director of Agency:
Name________________________________________ Phone
Contact Person:
Name________________________________________ Phone
E-mail address________________________________________________________________
Hours to Call__________________________________ Fax
Do you have federal tax exempt status under 501(c) (3) of the Federal Code? Yes No
Are you a church, synagogue, or other place of worship? Yes No
Do you receive USDA commodities? Yes No
If yes, from whom? ____________________________________________________________
____________________________________________________________________________
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Has your food program been in operation for at least 6 months? Yes No
How many individuals serve on BOD? _____ How often do they meet? _________________
How is your program funded?
Does your agency submit an I-990? Yes No Is your agency audited annually? Yes No
Do you at any time ask those you serve for a donation? Yes No
If yes, please explain
Would your organization be able to pay the shared maintenance fee charged by the
Houston Food Bank? Yes No (Please attach a copy of your current budget)
If no, please explain
Would you be able to comply with submission of monthly statistics forms to HFB? Yes No
Would you be able to comply with the perpetual inventory procedures? Yes No
Check the category or categories that best describe your program:
Food Pantry (any facility that distributes uncooked food to its clients)
Mobile Distribution (Mobile units)
Food Fairs (Agency must have Food Dealers Permit)
Meal Site / Residential Facility (any facility that cooks food before distributing it to its clients)
Do you have other sources for obtaining food? Yes No
If yes, please explain
Does your agency have written client eligibility requirements, or rules for acceptance and
participation in program? Yes No If yes: (Submit a copy)
If no: (Please explain process) ___________________________________________________
____________________________________________________________________________
Does your agency have an intake, or application, to gather information and screen for eligibility?
Yes No If yes: (Submit a copy)
If no: (Please explain process)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Are written records kept on clients receiving food? Yes No
How many paid staff members? _____ How many volunteer staff members? _____
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Pantry Programs
Approximately how many families do you serve per month? _______ Individuals?
Do you have a current Food Dealer’s Permit? Yes No (If no, call county health
department)
Who is the primary recipient of your program?
What kind of food do you most often supply?
Do you have adequate storage space for your program? Yes No
Do you have adequate refrigeration? Yes No
Do you have adequate freezer storage? Yes No
What days and hours is your pantry open? __________________________________________
What is the geographic (or zip code) area you serve?
Are you affiliated with any other agency? Yes No If yes, please explain:
_______________________
Meal Site / Residential Programs
Meals provided: Breakfast Lunch Dinner
Approximately how many individuals are served per meal?
What days do you serve meals? Sun Mon Tues Wed Thurs Fri Sat
Do you charge for meals? Yes No
Do you keep records of menus for every meal? Yes No
How many meals are served each week?
Do you have adequate food storage space for your program? Yes No
Do you have adequate refrigeration? Yes No
Do you have adequate freezer storage? Yes No
Do you have a current Health Inspection Report? Yes No (If no, call county health
department)
Do you have a Food Service Manager’s Certificate? Yes No (If no, call county health
department)
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Is your program a residential program? Yes No (If yes, answer the remaining
questions)
If residential program, how many beds is your facility licensed to have?
Do you have a State License? Yes No (If no, contact appropriate state
agency)
Do you have an Occupancy Permit? Yes No (If no, contact appropriate state
agency)
If residential, what is the average number of clients in residence on any given night?
Is your program a personal care facility? Yes No If not, what kind of facility is it? _______
____________________________________________________________________________
Is there a program fee? Yes No If yes, please explain:_____________________________
____________________________________________________________________________
Does everyone pay the complete fee? Yes No
MOBILE DISTRIBUTION UNITS
Must schedule at least 14 days in advance
Must have adequate space for delivery & safe storage
Agency is responsible for damages while unit is on their premises
Agency must provide a Social Service for clients, a flyer must be sent to Agency Service prior to
obtaining a mobile unit.
Agency must leave any unused products on mobile unit to be returned to the Houston Food
Bank
When complete please return to:
Department of Agency Services
The Houston Food Bank
535 Portwall
Houston, TX 77029
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Questions concerning the application process or the status of your application should be
directed to the Department of Agency Services, (713) 547-8668.
Certification: I certify that the above information is correct to the best of my knowledge.
Signed, Director of Agency or Program
Signed, Pastor of Church (if applicable)
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights
regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in
or administering USDA programs are prohibited from discriminating based on race, color, national origin,
sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity
conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g.
Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local)
where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may
contact USDA through the Federal Relay Service at (800) 877- 8339. Additionally, program information
may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint
Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA
office, or write a letter addressed to USDA and provide in the letter all of the information requested in the
form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter
to USDA by:
(1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400
Independence Avenue, SW Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov.
This institution is an equal opportunity provider.
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CHECK LIST
Items Needed for Application: Pantry Program
***ALL APPLICATIONS MUST INCLUDE A $25.00 NON-REFUNDABLE
APPLICATION FEE***
1.____ Copy of the IRS letter that your organization received attesting to your acceptance into
the 501(c) (3) tax category.
Or
2.____ Copy of a letter from your denominational office stating your organization’s affiliation
with the denomination or copies of the denomination’s regional/local directory cover
including the page on which your church’s name appears.
NOTE: If the applying program is not a church, but an agency, and is covered by a
group 501(c) (3), send proof of such affiliation.
3.____ Copy of the current Food Dealer’s Permit (If required by your county’s health
department.)
4.____ Description of your organization’s mission, goals, programs, services, and operation
procedures. (Include the zip codes/areas that you serve, your operation times, and etc.)
5.____ Copy of the written eligibility requirements used to determine client eligibility for your
program.
6.____ Copy of Budget showing amount budgeted for food cost.
7.____ List of food program workers.
8.____ Completed copy of the Food Bank Application.
Items Needed for Application: Meal Site Program
1.____ Copy of the IRS letter that your organization received attesting to your acceptance into
the 501(c) (3) tax category.
Or
2.____ Copy of a letter from your denominational office stating your organization’s affiliation
with the denomination or copies of the denomination’s regional/local directory cover
including the page on which your church’s name appears.
NOTE: If the applying program is not a church, but an agency, and is covered by a
group 501(c) (3) sends proof of such affiliation.
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3.____ Copy of the current Health Inspection Report of the kitchen and food storage areas.
4.____ Copy of the current Food Service Manager’s Certificate(s).
5.____ Description of your organization’s mission, goals, programs, services, and operation
procedures. (Include the zip codes/areas that you serve, your operation times, and etc.)
6.____ Copy of the written eligibility requirements used to determine client eligibility for your
program.
7.____ Copy of the Intake Form or Client Application used to gather information and screen
clients for program eligibility (Include a space for client’s signature.)
8.____ Copy of the daily Tally Sheet that includes clients’ date of service, name, and number
of meals served daily.
9.____ Copy of dated menus.
10.____ Completed copy of the Food Bank Application form.
Items Needed for Application: Residential Program
1.____ Copy of the IRS letter that your organization received attesting to your acceptance into
the 501(c) (3) tax category.
2.____ Copy of the current Health Inspection Report of the kitchen and food storage areas.
3.____ Copy of the current Food Service Manager’s Certificate(s).
4.____ Description of the organization’s mission, goals, programs, services, and operation
procedures. (Include the zip codes/areas that you serve, your operation times, & etc.)
5.____ Copy of the written eligibility requirements used to determine client eligibility for your
program.
6.____ Copy of the Intake Form or Client Application used to gather information and screen
clients for program eligibility (Include a space for client’s signature.)
7.____ Copy of the daily Tally Sheet that includes clients’ date of service, name, and number
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of meals served daily.
8.____ Copy of dated menus.
9.____ Copy of the Occupancy Permit from the city where your program operates.
10.____ Copy of the State License.
11.____ If you charge clients a fee for services, submit your official sliding scale policy, what
percentage of your total budget is provided by client fees, and the percentage of client
fees coming from various sources (SSI, TDHS, TRC, etc.). State basic fee for clients
paying full fee and reimbursements received from referring or reimbursing agencies.
12.____ Completed copy of the Food Bank Application form.
Items Needed for Application: Mobile Distribution
1.____ Copy of the IRS letter that your organization received attesting to your acceptance into
the 501(c) (3) tax category.
Or
2. ____ Copy of a letter from your denominational office stating your organization’s affiliation
with the denomination or copies of the denomination’s regional/local directory cover
including the page on which your church’s name appears.
NOTE: If the applying program is not a church, but an agency, and is covered by a
group 501(c) (3), send proof of such affiliation.
3.____ Description of the organization’s mission, goals, programs, services, and operation
procedures. (Include the zip codes/areas that you serve, your operation times, & etc.)
4.____ Copy of the written eligibility requirements used to determine client eligibility for your
program.
5.____ List of volunteers
6. ____Copy of Organization’s Current Budget
6.____ Completed copy of the Food Bank Application form.
