First Name: * Required Last Name: * Required Title: * Required Organization FEIN: Facility Name: * Required Facility Email: * Required Invalid Email Address Email Verification: * Required Invalid Email Address Telephone Number: Ext: Fax Number:   Mailing Address 1: * Required Mailing Address 2: City: Abbeville Adams Run Adamsburg Adrian Aiken Alcolu Allendale Alvin Anderson Andrews Angelus Antioch Appleton Arcadia Arcadia Lakes Ashepoo Ashland Ashton Atkins Atlantic Beach Awendaw Aynor Baldock Ballentine Bamberg Barnwell Barton Batesburg Batesburg-Leesville Bath Beaufort Beech Island Belton Belvedere Bennetts Point Bennettsville Bethel Bethera Bethune Bishopville Blackburg Blacksburg Blackstock Blackville Blair Blenheim Blue Brick Bluff Estates Bluffton Blythewood Boiling Springs Bonneau Borden Bowling Green Bowman Boykin Bradley Branchville Briarcliffe Acres Brittons Neck Brunson Bucksport Bucksville Buffalo Burgess Burnettown Burton Burton Branch Cades Caesars Head Cainhoy Calhoun Calhoun Falls Callawassie Island Callison Camden Cameron Campobello Canadys Candays Carlisle Carnes Crossroads Cartersville Cassatt Catawba Cateechee Cayce Centenary Central Central Pacolet Chapin Chappells Charleston Charleston AFB Charleston Heights Cheraw Cherokee Falls Cherry Grove Cherry Grove Beach Chesnee Chester Chesterfield Clarks Hill Claussen Clearwater Clemson Cleveland Clifton Clinton Clio Clover Clyde Columbia Conestee Congaree Conronaca Converse Conway Cooper Coosawhatchie Cope Cordesville Cordova Cottageville Coward Cowpens Crescent Beach Creston Crocketville Cross Cross Anchor Cross Hill Dacusville Dale Dalzell Daniel Island Darlington Daufuskie Island Davis Station Denmark Dentsville Dewees Island Dillon Dixiana Donalds Dorchester Dovesville Drake Drayton Due West Dunbarton Duncan Early Branch Easley Eastover Eau Claire Edgefield Edgemoor Edisto Edisto Beach Edisto Island Edmund Effingham Ehrhardt Elgin Elko Ellenton Elliott Elloree Enoree Estill Eureka Eutaw Springs Eutawville Fair Play Fairfax Fairforest Fairmont Filbert Fingerville Florence Floyd Dale Folly Beach Forest Acres Foreston Fork Fort Jackson Fort Lawn Fort Mill Fort Motte Fountain Inn Four Holes Fripp Island Frogmore Furman Gable Gadsden Gaffney Galivants Ferry Garden City Garden City Beach Gardens Corner Garnett Gaston Georgetown Gifford Gilbert Glendale Glenn Springs Gloverville Goose Creek Govan Gramling Graniteville Gray Court Grays Great Falls Greeleyville Green Pond Green Sea Greenville Greenwood Greer Gresham Grover Hagood Hamer Hampton Hanahan Harbison Hardeeville Harleyville Hartsville Heath Springs Helena Hemingway Hickory Grove Hilda Hilton Head Hilton Head Island Hodges Holly Hill Hollywood Honea Path Honey Hill Hopkins Horatio Huger Indian Land Inman Irmo Islandton Isle of Palms Iva Jackson Jacksonboro James Island Jamestown Jamison Jefferson Jenkinsville Jericho Joanna Johns Island Johnsonville Johnston Johnstown Joint Base Charleston Jonesville Kelton Kershaw Kiawah Island Killian Kinards Kings Creek Kingstree Kirkwood Kline Knightsville La France Ladson Ladys Island Lake City Lake Murray Lake View Lake Wylie Lamar Lancaster Lando Landrum Lane Lanford Langley Latta Laurel Bay Laurens Leeds Leesville Lesslie Lexington Liberty Liberty Hill Lincolnville Litchfield Little Mountain Little River Little Rock Livingston Livington Lobeco Lockhart Lodge Lone Star Long Creek Longcreek Longs Loris Lowndesville Lowrys Lugoff Luray Lydia Lyman Lynchburg Macbeth Madison Manning Marietta Marion Mars Bluff Martin Maryville Mauldin Mayesville Mayo McBee McClellanville McColl McConnells McCormick Meggett Midway Miley Millett Minturn Modoc Moncks Corner Monetta Mont Clare Monticello Montmorenci Moore Mount Carmel Mount Croghan Mount Holly Mount Pleasant Mountain Rest Mountville Mullins Murrells Inlet Myers Myrtle Beach Neeses Nesmith New Ellenton New Zion Newberry Newry Nichols Nimmons Ninety Six Nixonville Nixville Norris North North Augusta North Charleston North Litchfield North Myrtle Beach Norway Oakley Oamplico Ocean Drive Ocean Drive Beach Okatie Olanta Olar Ora Orangeburg Osborn Oswego Owings Pacolet Pacolet Mills Pageland Pamplico Parksville Parr Parris Island Patrick Pauline Pawleys Island Paxville Peak Peedee Pelion Pelzer Pendleton Perry Pickens Piedmont Pine Ridge Pineland Pineridge Pineville Pinewood Pinopolis Pisgah Plantersville Pleasant Hill Plum Branch Pomaria Pontiac Port Royal Poston Powdersville Princeton Pritchardville Prosperity Quinby Rains Ravenel Reevesville Reidville Rembert Richburg Richland Richtex Ridge Spring Ridgeland Ridgeville Ridgeway Ridgewood Rimini Rion Ritter River Hills Rock Hill Rockville Rodman Roebuck Round O Round Rock Rowesville Ruby Ruffin Russellville Saint Charles Saint George Saint Helena Island Saint Matthews Saint Stephen Salem Salley Salters Saluda Sandy Springs Santee Sardinia Sardis Scotia Scranton Seabrook Seabrook Island Sedelia Sellers Seneca Sharon Shaw AFB Sheldon Shelton Shirley Shoals Junction Shulerville Silverstreet Simpsonville Singleton Six Mile Slater Smoaks Smyrna Snelling Socastee Society Hill South Congaree South of the Border Spartanburg Spring Island Springdale Springfield St. George St. Matthews St. Stephen Starr Startex State Park Stateburg Stiefeltown Strother Stuckey Sullivans Island Summerton Summerville Summit Sumter Sunset Surfside Surfside Beach Swansea Switzerland Sycamore Tamassee Tatum Taylors Tega Cay The Citadel Tigerville Tillman Timmonsville Toddville Townville Travelers Rest Trenton Trio Troy Turbeville Ulmer Una Union Valley Falls Van Wyck Vance Varnville Vaucluse Verdery Wadmalaw Island Wagener Walhalla Wallace Walterboro Wando Ward Ware Shoals Warrenville Wateree Waterloo Wedgefield Wellford West Columbia West Pelzer West Union Westminster Westville White Hall White Oak White Rock White Stone Whitmire Whitney Wilkins Williams Williamston Willington Williston Wilson Windsor Winnsboro Wisacky Woodford Woodruff Woodward Yemassee Yonges Island York * Required State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands of the U.S. * Required County: Abbeville Aiken Allendale Anderson Bamberg Barnwell Beaufort Berkeley Calhoun Charleston Cherokee Chester Chesterfield Clarendon Colleton Darlington Dillon Dorchester Edgefield Fairfield Florence Georgetown Greenville Greenwood Hampton Horry Jasper Kershaw Lancaster Laurens Lee Lexington Marion Marlboro McCormick Newberry Oconee Orangeburg Pickens Richland Saluda Spartanburg Sumter Union Williamsburg York * Required Zip Code: 26456 29001 29002 29003 29006 29009 29010 29014 29015 29016 29018 29020 29021 29030 29031 29032 29033 29036 29037 29038 29039 29040 29041 29042 29044 29045 29046 29047 29048 29051 29052 29053 29054 29055 29056 29058 29059 29061 29062 29063 29065 29067 29069 29070 29071 29072 29073 29074 29075 29078 29079 29080 29081 29082 29101 29102 29104 29105 29107 29108 29111 29112 29113 29114 29115 29116 29117 29118 29122 29123 29125 29126 29127 29128 29129 29130 29132 29133 29135 29137 29138 29142 29143 29145 29146 29147 29148 29150 29151 29152 29153 29154 29160 29161 29162 29163 29164 29166 29168 29169 29170 29171 29172 29175 29177 29178 29180 29201 29202 29203 29204 29205 29206 29207 29208 29209 29210 29211 29212 29214 29215 29216 29217 29218 29219 29220 29221 29222 29223 29224 29225 29226 29227 29228 29229 29230 29240 29250 29260 29290 29292 29301 29302 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Brittons Neck Brunson Bucksport Bucksville Buffalo Burgess Burnettown Burton Burton Branch Cades Caesars Head Cainhoy Calhoun Calhoun Falls Callawassie Island Callison Camden Cameron Campobello Canadys Candays Carlisle Carnes Crossroads Cartersville Cassatt Catawba Cateechee Cayce Centenary Central Central Pacolet Chapin Chappells Charleston Charleston AFB Charleston Heights Cheraw Cherokee Falls Cherry Grove Cherry Grove Beach Chesnee Chester Chesterfield Clarks Hill Claussen Clearwater Clemson Cleveland Clifton Clinton Clio Clover Clyde Columbia Conestee Congaree Conronaca Converse Conway Cooper Coosawhatchie Cope Cordesville Cordova Cottageville Coward Cowpens Crescent Beach Creston Crocketville Cross Cross Anchor Cross Hill Dacusville Dale Dalzell Daniel Island Darlington Daufuskie Island Davis Station Denmark Dentsville Dewees Island Dillon Dixiana Donalds Dorchester Dovesville Drake Drayton Due West Dunbarton Duncan Early Branch Easley Eastover Eau Claire Edgefield Edgemoor Edisto Edisto Beach Edisto Island Edmund Effingham Ehrhardt Elgin Elko Ellenton Elliott Elloree Enoree Estill Eureka Eutaw Springs Eutawville Fair Play Fairfax Fairforest Fairmont Filbert Fingerville Florence Floyd Dale Folly Beach Forest Acres Foreston Fork Fort Jackson Fort Lawn Fort Mill Fort Motte Fountain Inn Four Holes Fripp Island Frogmore Furman Gable Gadsden Gaffney Galivants Ferry Garden City Garden City Beach Gardens Corner Garnett Gaston Georgetown Gifford Gilbert Glendale Glenn Springs Gloverville Goose Creek Govan Gramling Graniteville Gray Court Grays Great Falls Greeleyville Green Pond Green Sea Greenville Greenwood Greer Gresham Grover Hagood Hamer Hampton Hanahan Harbison Hardeeville Harleyville Hartsville Heath Springs Helena Hemingway Hickory Grove Hilda Hilton Head Hilton Head Island Hodges Holly Hill Hollywood Honea Path Honey Hill Hopkins Horatio Huger Indian Land Inman Irmo Islandton Isle of Palms Iva Jackson Jacksonboro James Island Jamestown Jamison Jefferson Jenkinsville Jericho Joanna Johns Island Johnsonville Johnston Johnstown Joint Base Charleston Jonesville Kelton Kershaw Kiawah Island Killian Kinards Kings Creek Kingstree Kirkwood Kline Knightsville La France Ladson Ladys Island Lake City Lake Murray Lake View Lake Wylie Lamar Lancaster Lando Landrum Lane Lanford Langley Latta Laurel Bay Laurens Leeds Leesville Lesslie Lexington Liberty Liberty Hill Lincolnville Litchfield Little Mountain Little River Little Rock Livingston Livington Lobeco Lockhart Lodge Lone Star Long Creek Longcreek Longs Loris Lowndesville Lowrys Lugoff Luray Lydia Lyman Lynchburg Macbeth Madison Manning Marietta Marion Mars Bluff Martin Maryville Mauldin Mayesville Mayo McBee McClellanville McColl McConnells McCormick Meggett Midway Miley Millett Minturn Modoc Moncks Corner Monetta Mont Clare Monticello Montmorenci Moore Mount Carmel Mount Croghan Mount Holly Mount Pleasant Mountain Rest Mountville Mullins Murrells Inlet Myers Myrtle Beach Neeses Nesmith New Ellenton New Zion Newberry Newry Nichols Nimmons Ninety Six Nixonville Nixville Norris North North Augusta North Charleston North Litchfield North Myrtle Beach Norway Oakley Oamplico Ocean Drive Ocean Drive Beach Okatie Olanta Olar Ora Orangeburg Osborn Oswego Owings Pacolet Pacolet Mills Pageland Pamplico Parksville Parr Parris Island Patrick Pauline Pawleys Island Paxville Peak Peedee Pelion Pelzer Pendleton Perry Pickens Piedmont Pine Ridge Pineland Pineridge Pineville Pinewood Pinopolis Pisgah Plantersville Pleasant Hill Plum Branch Pomaria Pontiac Port Royal Poston Powdersville Princeton Pritchardville Prosperity Quinby Rains Ravenel Reevesville Reidville Rembert Richburg Richland Richtex Ridge Spring Ridgeland Ridgeville Ridgeway Ridgewood Rimini Rion Ritter River Hills Rock Hill Rockville Rodman Roebuck Round O Round Rock Rowesville Ruby Ruffin Russellville Saint Charles Saint George Saint Helena Island Saint Matthews Saint Stephen Salem Salley Salters Saluda Sandy Springs Santee Sardinia Sardis Scotia Scranton Seabrook Seabrook Island Sedelia Sellers Seneca Sharon Shaw AFB Sheldon Shelton Shirley Shoals Junction Shulerville Silverstreet Simpsonville Singleton Six Mile Slater Smoaks Smyrna Snelling Socastee Society Hill South Congaree South of the Border Spartanburg Spring Island Springdale Springfield St. George St. Matthews St. Stephen Starr Startex State Park Stateburg Stiefeltown Strother Stuckey Sullivans Island Summerton Summerville Summit Sumter Sunset Surfside Surfside Beach Swansea Switzerland Sycamore Tamassee Tatum Taylors Tega Cay The Citadel Tigerville Tillman Timmonsville Toddville Townville Travelers Rest Trenton Trio Troy Turbeville Ulmer Una Union Valley Falls Van Wyck Vance Varnville Vaucluse Verdery Wadmalaw Island Wagener Walhalla Wallace Walterboro Wando Ward Ware Shoals Warrenville Wateree Waterloo Wedgefield Wellford West Columbia West Pelzer West Union Westminster Westville White Hall White Oak White Rock White Stone Whitmire Whitney Wilkins Williams Williamston Willington Williston Wilson Windsor Winnsboro Wisacky Woodford Woodruff Woodward Yemassee Yonges Island York * Required State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands of the U.S. * Required County: Abbeville Aiken Allendale Anderson Bamberg Barnwell Beaufort Berkeley Calhoun Charleston Cherokee Chester Chesterfield Clarendon Colleton Darlington Dillon Dorchester Edgefield Fairfield Florence Georgetown Greenville Greenwood Hampton Horry Jasper Kershaw Lancaster Laurens Lee Lexington Marion Marlboro McCormick Newberry Oconee Orangeburg Pickens Richland Saluda Spartanburg Sumter Union Williamsburg York * Required Zip Code: 26456 29001 29002 29003 29006 29009 29010 29014 29015 29016 29018 29020 29021 29030 29031 29032 29033 29036 29037 29038 29039 29040 29041 29042 29044 29045 29046 29047 29048 29051 29052 29053 29054 29055 29056 29058 29059 29061 29062 29063 29065 29067 29069 29070 29071 29072 29073 29074 29075 29078 29079 29080 29081 29082 29101 29102 29104 29105 29107 29108 29111 29112 29113 29114 29115 29116 29117 29118 29122 29123 29125 29126 29127 29128 29129 29130 29132 29133 29135 29137 29138 29142 29143 29145 29146 29147 29148 29150 29151 29152 29153 29154 29160 29161 29162 29163 29164 29166 29168 29169 29170 29171 29172 29175 29177 29178 29180 29201 29202 29203 29204 29205 29206 29207 29208 29209 29210 29211 29212 29214 29215 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29802 29803 29804 29805 29808 29809 29810 29812 29813 29816 29817 29819 29821 29822 29824 29826 29827 29828 29829 29831 29832 29834 29835 29836 29838 29839 29840 29841 29842 29843 29844 29845 29846 29847 29848 29849 29850 29851 29853 29856 29860 29861 29899 29901 29902 29903 29904 29905 29906 29907 29909 29910 29911 29912 29913 29914 29915 29916 29918 29920 29921 29922 29923 29924 29925 29926 29927 29928 29929 29931 29932 29933 29934 29935 29936 29938 29939 29940 29941 29943 29944 29945 * Required
1. Is this a Multi-state agency (Operates the CACFP in one or more states besides South Carolina)? Yes No 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))? Yes No If Yes, list the other program(s) that you currently administer.
3. Institution Type:	Government Organization (Public) Private NonProfit For-Profit Organization
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? Yes No 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: * Required Number of Facilities must be numeric			Number of Participants: * Required Number of Participants must be numeric
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:	* Required PO Box - Not Allowed
Address 2:	PO Box - Not Allowed
City:	Abbeville Adams Run Adamsburg Adrian Aiken Alcolu Allendale Alvin Anderson Andrews Angelus Antioch Appleton Arcadia Arcadia Lakes Ashepoo Ashland Ashton Atkins Atlantic Beach Awendaw Aynor Baldock Ballentine Bamberg Barnwell Barton Batesburg Batesburg-Leesville Bath Beaufort Beech Island Belton Belvedere Bennetts Point Bennettsville Bethel Bethera Bethune Bishopville Blackburg Blacksburg Blackstock Blackville Blair Blenheim Blue Brick Bluff Estates Bluffton Blythewood Boiling Springs Bonneau Borden Bowling Green Bowman Boykin Bradley Branchville Briarcliffe Acres Brittons Neck Brunson Bucksport Bucksville Buffalo Burgess Burnettown Burton Burton Branch Cades Caesars Head Cainhoy Calhoun Calhoun Falls Callawassie Island Callison Camden Cameron Campobello Canadys Candays Carlisle Carnes Crossroads Cartersville Cassatt Catawba Cateechee Cayce Centenary Central Central Pacolet Chapin Chappells Charleston Charleston AFB Charleston Heights Cheraw Cherokee Falls Cherry Grove Cherry Grove Beach Chesnee Chester Chesterfield Clarks Hill Claussen Clearwater Clemson Cleveland Clifton Clinton Clio Clover Clyde Columbia Conestee Congaree Conronaca Converse Conway Cooper Coosawhatchie Cope Cordesville Cordova Cottageville Coward Cowpens Crescent Beach Creston Crocketville Cross Cross Anchor Cross Hill Dacusville Dale Dalzell Daniel Island Darlington Daufuskie Island Davis Station Denmark Dentsville Dewees Island Dillon Dixiana Donalds Dorchester Dovesville Drake Drayton Due West Dunbarton Duncan Early Branch Easley Eastover Eau Claire Edgefield Edgemoor Edisto Edisto Beach Edisto Island Edmund Effingham Ehrhardt Elgin Elko Ellenton Elliott Elloree Enoree Estill Eureka Eutaw Springs Eutawville Fair Play Fairfax Fairforest Fairmont Filbert Fingerville Florence Floyd Dale Folly Beach Forest Acres Foreston Fork Fort Jackson Fort Lawn Fort Mill Fort Motte Fountain Inn Four Holes Fripp Island Frogmore Furman Gable Gadsden Gaffney Galivants Ferry Garden City Garden City Beach Gardens Corner Garnett Gaston Georgetown Gifford Gilbert Glendale Glenn Springs Gloverville Goose Creek Govan Gramling Graniteville Gray Court Grays Great Falls Greeleyville Green Pond Green Sea Greenville Greenwood Greer Gresham Grover Hagood Hamer Hampton Hanahan Harbison Hardeeville Harleyville Hartsville Heath Springs Helena Hemingway Hickory Grove Hilda Hilton Head Hilton Head Island Hodges Holly Hill Hollywood Honea Path Honey Hill Hopkins Horatio Huger Indian Land Inman Irmo Islandton Isle of Palms Iva Jackson Jacksonboro James Island Jamestown Jamison Jefferson Jenkinsville Jericho Joanna Johns Island Johnsonville Johnston Johnstown Joint Base Charleston Jonesville Kelton Kershaw Kiawah Island Killian Kinards Kings Creek Kingstree Kirkwood Kline Knightsville La France Ladson Ladys Island Lake City Lake Murray Lake View Lake Wylie Lamar Lancaster Lando Landrum Lane Lanford Langley Latta Laurel Bay Laurens Leeds Leesville Lesslie Lexington Liberty Liberty Hill Lincolnville Litchfield Little Mountain Little River Little Rock Livingston Livington Lobeco Lockhart Lodge Lone Star Long Creek Longcreek Longs Loris Lowndesville Lowrys Lugoff Luray Lydia Lyman Lynchburg Macbeth Madison Manning Marietta Marion Mars Bluff Martin Maryville Mauldin Mayesville Mayo McBee McClellanville McColl McConnells McCormick Meggett Midway Miley Millett Minturn Modoc Moncks Corner Monetta Mont Clare Monticello Montmorenci Moore Mount Carmel Mount Croghan Mount Holly Mount Pleasant Mountain Rest Mountville Mullins Murrells Inlet Myers Myrtle Beach Neeses Nesmith New Ellenton New Zion Newberry Newry Nichols Nimmons Ninety Six Nixonville Nixville Norris North North Augusta North Charleston North Litchfield North Myrtle Beach Norway Oakley Oamplico Ocean Drive Ocean Drive Beach Okatie Olanta Olar Ora Orangeburg Osborn Oswego Owings Pacolet Pacolet Mills Pageland Pamplico Parksville Parr Parris Island Patrick Pauline Pawleys Island Paxville Peak Peedee Pelion Pelzer Pendleton Perry Pickens Piedmont Pine Ridge Pineland Pineridge Pineville Pinewood Pinopolis Pisgah Plantersville Pleasant Hill Plum Branch Pomaria Pontiac Port Royal Poston Powdersville Princeton Pritchardville Prosperity Quinby Rains Ravenel Reevesville Reidville Rembert Richburg Richland Richtex Ridge Spring Ridgeland Ridgeville Ridgeway Ridgewood Rimini Rion Ritter River Hills Rock Hill Rockville Rodman Roebuck Round O Round Rock Rowesville Ruby Ruffin Russellville Saint Charles Saint George Saint Helena Island Saint Matthews Saint Stephen Salem Salley Salters Saluda Sandy Springs Santee Sardinia Sardis Scotia Scranton Seabrook Seabrook Island Sedelia Sellers Seneca Sharon Shaw AFB Sheldon Shelton Shirley Shoals Junction Shulerville Silverstreet Simpsonville Singleton Six Mile Slater Smoaks Smyrna Snelling Socastee Society Hill South Congaree South of the Border Spartanburg Spring Island Springdale Springfield St. George St. Matthews St. Stephen Starr Startex State Park Stateburg Stiefeltown Strother Stuckey Sullivans Island Summerton Summerville Summit Sumter Sunset Surfside Surfside Beach Swansea Switzerland Sycamore Tamassee Tatum Taylors Tega Cay The Citadel Tigerville Tillman Timmonsville Toddville Townville Travelers Rest Trenton Trio Troy Turbeville Ulmer Una Union Valley Falls Van Wyck Vance Varnville Vaucluse Verdery Wadmalaw Island Wagener Walhalla Wallace Walterboro Wando Ward Ware Shoals Warrenville Wateree Waterloo Wedgefield Wellford West Columbia West Pelzer West Union Westminster Westville White Hall White Oak White Rock White Stone Whitmire Whitney Wilkins Williams Williamston Willington Williston Wilson Windsor Winnsboro Wisacky Woodford Woodruff Woodward Yemassee Yonges Island York * Required	State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands of the U.S. * Required
County:	Abbeville Aiken Allendale Anderson Bamberg Barnwell Beaufort Berkeley Calhoun Charleston Cherokee Chester Chesterfield Clarendon Colleton Darlington Dillon Dorchester Edgefield Fairfield Florence Georgetown Greenville Greenwood Hampton Horry Jasper Kershaw Lancaster Laurens Lee Lexington Marion Marlboro McCormick Newberry Oconee Orangeburg Pickens Richland Saluda Spartanburg Sumter Union Williamsburg York * Required
Zip Code:	26456 29001 29002 29003 29006 29009 29010 29014 29015 29016 29018 29020 29021 29030 29031 29032 29033 29036 29037 29038 29039 29040 29041 29042 29044 29045 29046 29047 29048 29051 29052 29053 29054 29055 29056 29058 29059 29061 29062 29063 29065 29067 29069 29070 29071 29072 29073 29074 29075 29078 29079 29080 29081 29082 29101 29102 29104 29105 29107 29108 29111 29112 29113 29114 29115 29116 29117 29118 29122 29123 29125 29126 29127 29128 29129 29130 29132 29133 29135 29137 29138 29142 29143 29145 29146 29147 29148 29150 29151 29152 29153 29154 29160 29161 29162 29163 29164 29166 29168 29169 29170 29171 29172 29175 29177 29178 29180 29201 29202 29203 29204 29205 29206 29207 29208 29209 29210 29211 29212 29214 29215 29216 29217 29218 29219 29220 29221 29222 29223 29224 29225 29226 29227 29228 29229 29230 29240 29250 29260 29290 29292 29301 29302 29303 29304 29305 29306 29307 29316 29319 29320 29321 29322 29323 29324 29325 29329 29330 29331 29332 29333 29334 29335 29336 29338 29340 29341 29342 29346 29348 29349 29351 29353 29355 29356 29360 29364 29365 29368 29369 29370 29372 29373 29374 29375 29376 29377 29378 29379 29384 29385 29386 29388 29395 29401 29402 29403 29404 29405 29406 29407 29409 29410 29412 29413 29414 29415 29416 29417 29418 29419 29420 29422 29423 29424 29425 29426 29429 29431 29432 29433 29434 29435 29436 29437 29438 29439 29440 29442 29445 29446 29447 29448 29449 29450 29451 29452 29453 29455 29456 29457 29458 29461 29464 29465 29466 29468 29469 29470 29471 29472 29474 29475 29476 29477 29479 29481 29482 29483 29484 29485 29486 29487 29488 29492 29493 29501 29502 29503 29504 29505 29506 29510 29511 29512 29516 29518 29519 29520 29525 29526 29527 29528 29530 29532 29536 29540 29541 29543 29544 29545 29546 29547 29550 29551 29554 29555 29556 29560 29563 29564 29565 29566 29567 29568 29569 29570 29571 29572 29574 29575 29576 29577 29578 29579 29580 29581 29582 29583 29584 29585 29587 29588 29589 29590 29591 29592 29593 29594 29596 29597 29598 29601 29602 29603 29604 29605 29606 29607 29608 29609 29610 29611 29612 29613 29614 29615 29616 29617 29620 29621 29622 29623 29624 29625 29626 29627 29628 29630 29631 29632 29633 29634 29635 29636 29638 29639 29640 29641 29642 29643 29644 29645 29646 29647 29648 29649 29650 29651 29652 29653 29654 29655 29656 29657 29658 29659 29661 29662 29664 29665 29666 29667 29669 29670 29671 29672 29673 29675 29676 29677 29678 29679 29680 29681 29682 29683 29684 29685 29686 29687 29688 29689 29690 29691 29692 29693 29695 29696 29697 29702 29703 29704 29706 29707 29708 29709 29710 29712 29714 29715 29716 29717 29718 29720 29721 29722 29724 29726 29727 29728 29729 29730 29731 29732 29733 29734 29741 29742 29743 29744 29745 29801 29802 29803 29804 29805 29808 29809 29810 29812 29813 29816 29817 29819 29821 29822 29824 29826 29827 29828 29829 29831 29832 29834 29835 29836 29838 29839 29840 29841 29842 29843 29844 29845 29846 29847 29848 29849 29850 29851 29853 29856 29860 29861 29899 29901 29902 29903 29904 29905 29906 29907 29909 29910 29911 29912 29913 29914 29915 29916 29918 29920 29921 29922 29923 29924 29925 29926 29927 29928 29929 29931 29932 29933 29934 29935 29936 29938 29939 29940 29941 29943 29944 29945 * Required

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