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First Name:   Last Name:  
Organization FEIN:
Facility Name:  
Facility Email:    
Email Verification:    
Telephone Number: Ext:
Fax Number:
Mailing Address 1:  
Mailing Address 2:
City:   State:  
Zip Code:  
Physical Addr 1:  
Physical Addr 2:
City:   State:  
Zip Code:  

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

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))?

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

3. Institution Type:
4. Type of Program  

5. Have you ever participated in a Child Nutrition Program as an Institution or Facility?
If 'Yes', check all that apply:


6. Number of Facilities:       Number of Participants:      
7. Type of Food Service Operation (Check all that apply):

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


9. At what address are business records kept?

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

1. Do you have a Taxpayer Identification Number?

2. Are you currently excluded from any state or federally administered programs?

3. Which option best describes your organization?

4. Can you provide payroll records for at least two quarters (6 months)?