CSFP Site Interest Form

Fill out this form to find out more about becoming a distribution site for the Commodity Supplemental Food Program.

Interested in becoming a site in your community where seniors in need can pick up their free box of nutritional food once a month? Please let us know some more information to see if you are a good fit.

Organization Name(Required)

Organization Address(Required)

Street Address Address Line 2 City State ZIP Code

Contact Name(Required)

First Last

Contact Phone(Required)

Contact Email(Required)

Do you have secured storage that could fit leftover boxes?(Required)

Yes

Do you have secured fridge storage for leftover cheese?(Required)

Yes

Is someone at the organization interested in managing paperwork and distribution boxes once a month?(Required)

Yes

Comments

This field is for validation purposes and should be left unchanged.

This institution is an equal opportunity provider.

CICOA Aging & In-Home Solutions is committed to your privacy and to the protection of your personal information. Your information is submitted securely and will only be used for the purposes of the CSFP program.