HomeMy WebLinkAbout2. Sample 1 Food Donation Agreement Form
Appendix D. Food Donation Agreement Form
DONOR AND RECIPIENT INFORMATION
Food DONOR Facility/Organization Name Food RECIPIENT Facility/Organization Name
DONOR Representative Name RECIPIENT Representative Name
Business Address Business Address
Phone Email Phone Email
DONATED FOOD PRODUCT INFORMATION
FOOD PRODUCT PACKAGING STORAGE CONDITIONS
CHECK ALL
THAT APPLY
QUANTITY &
FREQUENCY
Prepared Foods Food-grade packaging Chilled to 41F or below, or
frozen at 0F or below
Chilled Perishable
Prepackages Foods
Original packaging OR
food-grade packaging
Chilled to 41F or below
Meat, poultry, fish
(fresh)
Original packaging OR
food-grade packaging
Chilled to 41F or below
Meat, poultry, fish
(frozen)
Original packaging OR
food-grade packaging
Frozen at 0F or below
Dairy Products Original packaging OR
food-grade packaging
Chilled to 41F or below
Shelf stable foods Original packaging
Other
TRANSPORTATION
Describe how food will be transported. Include pickup frequencies and how food will be
packaged for transport (e.g. in coolers, in refrigerated truck), and time and temperature tracking
protocol. (See sample Food Donation Delivery Form included.)
FOOD DONATION
AGREEMENT FORM
TOPIC FOOD DONOR ORGANIZATION FOOD RECIPIENT ORGANIZATION
Food training and experience of
food manager or person-in-charge
(e.g. ServSafe training)
Allergen and cross-contamination
awareness and training
Best time and methods for
communicating
USE THIS SPACE FOR ANY ADDITIONAL CONSIDERATIONS
We agree to abide by the agreements we have made, provide appropriate management and
supervision to ensure safe food handling and donation, and to promptly communicate
unsatisfactory conditions. We agree to handle food in accordance with the California Retail Food
Code, to ensure that every effort is taken to provide apparently wholesome food to those in need.
Signature of Food DONOR Representative Date
Printed Name of Food DONOR Representative
Signature of Food RECIPIENT Representative Date
Printed Name of Food RECIPIENT Representative
FOR MORE INFORMATION contact City of Diamond Bar Environmental Services at greenDB@DiamondBarCA.gov