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Feeding Coordination Signup Form

2. Wayne County Feeding Coordination Signup
   Restaurants must be able to provide a meal for $3 or less

   Restaurants must be able to provide a meal for $3 or less

4. Name of Restaurant/Company*

6. Physical Address*

8. City*

9. State*

10. Zip Code*

12. Mailing Address (If different)

14. City

15. State

16. Zip Code

18. Contact Name (First Name)*

19. Contact Name (Last Name)*

21. Main Phone Number*

22. Cell Phone Number*

24. Will you be able to provide itemized invoices?*

    1. Yes
    2. No

26. Maximum number of meals you can prepare at one time?*

Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field