home | Outreach Center Application

Outreach Center Application

Please complete this form to begin the process of becoming an official outreach center. Please note that missing or omitted information my lengthen the process of approving your application.

Church/Organization Name**REQUIRED
EIN Tax Number**REQUIRED
Mailing Address**REQUIRED
Mailing City**REQUIRED
Mailing State **REQUIRED
Mailing ZIP CODE**REQUIRED
Physical Address**ONLY IF DIFFERENT FROM THE MAILING ADDRESS
Physical City
Physical State
Physical ZIP CODE
Church/Organization Email Address**REQUIRED
Church/Organization Phone Number**REQUIRED
Church/Organization Website

POINT OF CONTACT INFO


In order for us to better serve you, we need to know specific points of contact within your organization.

Pastor/Leader Full Name**REQUIRED
Pastor/Leader Email Address**REQUIRED
Pastor/Leader Phone**REQUIRED
 
Outreach Center Evangelist Full Name
Outreach Center Evangelist Email Address
Outreach Center Evangelist Phone
 
Outreach Center Evangelist Assistant Full Name
Outreach Center Evangelist Assistant Email Address
Outreach Center Evangelist Assistant Phone


Additional Required Info
Who referred you to HIS food ministry?**REQUIRED
Preferred Day of Delivery #1**REQUIRED
Preferred Day of Delivery #2**REQUIRED
What type of facility will you use for distributions?**REQUIRED



Commitment and Responsibility Agreement

Please read the following statements, click the checkbox and type in your initials to confirm your understanding.

  • Any applicable sales tax must be collected, reported and paid by the outreach center to their states department of revenue. Not all states collect sales tax on food; please contact your state revenue office for correct information.
  • I understand I cannot place a order until I am officially approved by HIS food ministry and receive my Identification number.

 By checking this box, I confirm my responsiblity as an Outreach Center   **REQUIRED
   Type your initials here as your electronic signature:   **REQUIRED



AUTHORIZATION AGREEMENT FOR ORIGINATION OF ACH ENTRIES (ACH CREDITS OR DEBITS)
Church/Organization Name

I (we) hereby authorize HIS food ministry hereinafter called Church, to initiate automated clearinghouse entries to my (our) indicated below and the depository named below, herein called DEPOSITORY, to credit and/or debit the same to such account.

Depository Name
Branch
Branch City
Branch State
Branch ZIP CODE
 
TRANSIT/ABA Number
Account Number

This authority is to remain in full force and effect until CHURCH has received written notification from me (or either of us) of its termination in such time and manner as to afford CHURCH and DEPOSITORY a reasonable opportunity to act on it.

Your Full Name

 By checking this box, I approve HIS Food Ministry to process ACH transactions for our monthly orders.
   Type your initials here as your electronic signature: 



ANTI-SPAM PROTECTION

To ward off spammers, please complete the simple puzzle below:

Drag the World to the circle on the side.


Upon submission of this form, you will receive a confirmation email with an activation link via email.
YOU MUST click the activation link to confirm your identity.


Your APPLICATION will be processed WHEN YOU PRESS THIS BUTTON:

* If you do not receive a confirmation email after submitting your application please e mail Pastor Ron at pastorron@hisfoodministry.net or feel free to contact Pastor Ron or Roy Jones at 1-855-HIS-SOUL. We want to assure you that each and every application is handled properly and professionally.