| SECTION 1.0 |
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| Organization Name |
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| Primary Contact Name: |
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| Phone Number: |
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* |
| Email Address: |
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| Website (if any): |
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| Physical Mailing Address: |
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| How Did You Hear About Us? |
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| SECTION 2.0 |
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| Destination Country(s): |
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| Destination City(s) or Region(s): |
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| Is This a New or Existing Program? |
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| If Existing, Length of Time the Program Has Been Operating: |
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| Type of Program: |
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| Number of Children Being Fed: |
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| Number of Adults Being Fed: |
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| Number of Elderly Being Fed: |
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| Feeding Program Method (check all that apply): |
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| List Other Food Aid Being Received, How Much, And How Often Is It Received?: |
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* |
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| SECTION 3.0 |
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| Organization: |
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| Primary Contact Name: |
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* |
| Telephone Number: |
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* |
| Email Address: |
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* |
| Physical Mailing Address: |
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* |
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| SECTION 4.0 |
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| NOTE: |
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| Consignee Organization Name: |
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| Primary Contact: |
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| Telephone Number: |
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| Physical Address: |
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| SECTION 5.0 |
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| NOTE: |
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| Number of Meals You are Applying for (check only one from the list). If OTHER, indicate how many pallets (7,128 one cup meals per pallet): |
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| FMSC requires the receiving organization to pay for all transportation and distribution costs. Are funds currently available? |
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| If NO, please indicate the time needed to obtain funding. |
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| Do You Have Tax Exempt Status in the Receiving Country? |
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| Have You Successfully Imported and Distributed Food Aid Before? |
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| If Yes, When, Where, How Much? |
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| Freight Forwarder Telephone: |
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| NOTE: |
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| Freight Forwarder Email: |
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| Freight Forwarder Company: |
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| Freight Forwarder Contact: |
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| NOTE: |
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| Are You Able To Provide Feedback As Noted? |
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* |
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| Is There Any Additional Information You Would Like To Add To Support Your Application? |
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