Request for Bargain Box Vouchers

*Name of Agency:

*Physical address:

Mailing address (if different from physical address):

*City and State:

*Zip:

*Agency phone number:

Website:

*Authorized Contact:

*Contact phone number:

*Contact email address:

Is this a nonprofit agency?

Yes
No

*Tax ID Number:

Any additional DBA’s:

*Agency’s mission (please limit to 300 words or less):

*Agency’s target population (i.e. – children, elderly, diasabled etc.) Please list all that apply:

*Number of people served annually:

*In 300 words or less, please describe the services provided by your agency:

*Why would the Bargain Bucks Voucher Program be beneficial to your agency or specific needs (i.e. – coats for children, work attire for adults)?

* I understand submission of this request for inclusion in the Bargain Box Vouchers Program does not guarantee acceptance. Additionally, my submission confirms that I have answered these questions truthfully.

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