Agency Survey Agency Survey Contact Name* Contact Title* Agency Name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Agency Website Agency Mission or Purpose Statement (if available)Please define your agency's boundaries*What is the highest number of unduplicated people you serve at a distribution?* Does your agency distribute food:* Weekly Biweekly Monthly As Needed Other (please see next question) If you chose "Other" in the previous question, please explain when your agency distributes food:Does your agency have enough refrigeration to store the amount of milk needed for a distribution? (*Please note one milk crate holds 16 quarts)*YesNoMy agency agrees to contribute $.50 to Second Harvest per quart of milk received.*YesNoMy agency submits all monthly reporting (i.e. statistics, retail pick up sheets, etc.) in a timely manner to Second Harvest*YesNoMy agency is prompt with payments to Second Harvest*YesNoFor agencies that pick up products at Second Harvest: my agency has refrigeration or passive refrigeration to maintain proper temperature while transporting from Second Harvest to my agencyYesNoNameThis field is for validation purposes and should be left unchanged.
