Information Change Form

• Please fill in the changes that need to be made:
• Agency Name (If Applicable)*
  Agency Name (If Applicable)
• Food Pantry Address*
  Physical Address City State Zip Code
• Director's Information
• First
  First
• Last
  Last
• Director Phone Number*
  Director Phone Number
• Email (New Director)*
  Email
• Shoppers and Contact Numbers
• Delete Shoppers?
  Would you like to delete shoppers?
  • Yes
  • No
• The following shoppers will be DELETED
• Name (New Shopper or Phone Number Change for current shopper)
  Name
• Phone Number (New Shopper or Phone Number Change for current shopper)
  Phone Number
• Name (New Shopper or Phone Number Change for current shopper)
  Name
• Phone Number (New Shopper or Phone Number Change for current shopper)
  Phone Number
• Name (New Shopper or Phone Number Change for current shopper)
  Name
• Phone Number (New Shopper or Phone Number Change for current shopper)
  Phone Number
• Name (New Shopper or Phone Number Change for current shopper)
  Name
• Phone Number (New Shopper or Phone Number Change for current shopper)
  Phone Number
• Add Shoppers?
  Would you like to add shoppers?
  • Yes
  • No
• The following shoppers will be ADDED
• Name (New Shopper or Phone Number Change for current shopper)
  Name
• Phone Number (New Shopper or Phone Number Change for current shopper)
  Phone Number
• Name (New Shopper or Phone Number Change for current shopper)
  Name
• Phone Number (New Shopper or Phone Number Change for current shopper)
  Phone Number
• Name (New Shopper or Phone Number Change for current shopper)
  Name
• Phone Number (New Shopper or Phone Number Change for current shopper)
  Phone Number
• Name (New Shopper or Phone Number Change for current shopper)
  Name
• Phone Number (New Shopper or Phone Number Change for current shopper)
  Phone Number

• Section Break

• Days of Distribution (Please place an "X" on the days of operation)
• Days For Distribution of Food

  Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday

• Hours of Operation (Please indicate the hours of operation on the days you are open)
• Changes in Hours of Food Distribution

  Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday

• Comments
• Comments
• Person Submitting Changes
• Person Submitting Changes*
• Date of Submission
• Effective Date For Changes*
  Date Format: MM slash DD slash YYYY

• PLEASE RETAIN A COPY FOR YOUR RECORDS