Initial Screening

First Name:		Last Name:
Title:
Organization FEIN:
Facility Name:
Facility Email:
Email Verification:
Telephone Number:		Ext:
Fax Number:

Mailing Address 1:
Mailing Address 2:
City:		State:
County:
Zip Code:

Physical Addr 1:
Physical Addr 2:
City:		State:
County:
Zip Code:

1. Is this a Multi-state agency (Operates the CACFP in one or more states besides South Carolina)?

YesNo

If Yes, list the affiliated and/or unaffiliated facilities under this multi-state sponsoring organization and the state(s) in which they operate.

2. Is this agency a Muli-purpose organization (i.e., does the sponsor only operate CACFP, or is it part of a larger organization with other activities, such as Resource and Referral Services of programs such as Head Start, School Breakfast Program, The Emergency Food Assistance Program (TEFAP), National School Lunch Program (NSLP), or the Summer Food Service Program (SFSP))?

YesNo

If Yes, list the other program(s) that you currently administer.

3. Institution Type:

4. Type of Program

Child Care Center

Adult Care Center

At-Risk Afterschool Program

Outside School Hours

Emergency Shelter

Head Start

5. Have you ever participated in a Child Nutrition Program as an Institution or Facility?

YesNo

If 'Yes', check all that apply:

CACFP (Center/Home Child Care)
Emergency Shelter
Summer Food Service Program
At-Risk Afterschool Program
School Breakfast Program
National School Lunch Program
Other

6. Number of Facilities:

Number of Participants:

7. Type of Food Service Operation (Check all that apply):

Self-Preparation
Central Kitchen operated by Institution
Vended by private commercial company
Food Service Management Company
Other

8. What Meal Types does the Institution anticipate serving (Check all that apply)?:

Breakfast
AM Snack
Lunch
PM Snack
Supper
Evening Snack

9. At what address are business records kept?

Address 1:

Address 2:

City:

State:

County:

Zip Code:


1.	Do you have a Taxpayer Identification Number?
	Yes No

2.	Are you currently excluded from any state or federally administered programs?
	Yes No

3.	Which option best describes your organization?
	Child Care Center Adult Care Center Center Sponsor At-Risk Afterschool Program Emergency Shelter Outside School Hours Head Start Child Care Home Child Care Home Sponsor Don't Know


4.	Can you provide payroll records for at least two quarters (6 months)?
	Yes No