Mobile Pantry Request Form

Today's Date:(Required)

Name of Member(Required)

Name

Member Code(Required)

Code

Contact Name(Required)

First Last

Phone(Required)

Email(Required)

Date of Requested Pantry(Required)

Start Time of Pantry (if known)

:

Delivery Time Requested (if known)

:

Address of Mobile Pantry(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is this location owned by your organization or a third party?(Required)

Owned

Third Party

List any other organizations, if any, that you expect to support this Mobile Pantry (volunteers, space, financial support, etc?)(Required)

Will the pantry be hosted inside, outside, or a mix?(Required)

Inside

Outside

A mix of both.

(If known) If inside, can a pallet jack enter the location?

Yes

No

(If known) Are there any potential obstructions for a truck?

Yes

No

How many households are you planning to serve?(Required)

Please provide a summary of your funding plan for this Mobile Pantry (Box Truck size Mobile Pantry deliveries are $750 and Tractor-Trailer size are $1550):(Required)

Please provide a summary of your marketing/outreach plan to inform Neighbors of this Mobile Pantry opportunity:(Required)

Please provide a summary of your plan on how to manage any excess food due to low attendance. Note that all food delivered is the responsibility of the Member and the Food Bank of Northeast Georgia will not return to collect excess.(Required)