Senior Nutrition
Restaurant Partnership

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* 1. What is the name and address of your restaurant?

Restaurant's Name

Address

Zip Code

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* 2. Provide the contact information of the owner/manager.

Name

Email Address

Phone Number

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* 3. Please upload a copy of your restaurant's license.

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* 4. Have you had any health code violations in the past 3 years?

No

Yes. Please describe the violation(s) below.

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* 5. Do you have the capacity to prepare an additional 50-100 meals daily (M-F) for this program?

Yes

No

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* 6. Do you have the staff capacity to deliver 50-100 meals daily between 10:30 am - 3:30 pm?

Yes

No

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* 7. Please describe your anticipated delivery process including times of delivery.

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* 8. Do you have an invoicing system that can breakdown raw food costs?

Yes

No

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* 9. After reviewing the dietary criteria, please upload a minimum of 5-day sample menu.