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AGENCY REGISTRATION

Register your agency with Fields to Families:

 Agency Name
 Pastor or Director Name
 Address
 
 City, State, Zip
 Agency Email
 Agency Phone
 Agency Fax
 Agency Type
 Number Served
 501(c)3 Yes  No
 Agency Hours
 Contact Person
 Contact Position
 Contact Phone

 Please describe available transportation:
 

 Agency physical address & driving directions:
 

 Please describe available refrigeration:
 

 Please enter any additional comments:
 

Your digital signature below affirms that you will be responsible for providing to Fields to Families, the weight of produce or any other food received. It also affirms that when picking up produce, you will schedule and have a confirmed pick-up time for food/produce from its source of origin. Confirm your digital signature by entering your full name below.
 Signature