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Submit a Member Agency Application
New Member Agency Application for FY24 (July 1, 2023 to June 30, 2024)
Your Full Name
Your Email
PLEASE NOTE: ONLY ENTER NUMBERS IN THE PHONE NUMBER FIELDS;
adding text or other characters will cause an error in receiving your referral links.
Agency Information
Organization
Street Address
Lines one and two of address, if applicable
City
State
Zip
Executive Director/ CEO First Name
Last Name
Executive Director/ CEO Email
One email address only please
Primary Supervisor Responsible for Case Managers/Referral Staff
First Name
Last Name
Phone Number
Please enter numbers only.
Fax Number
Supervisor Email
One email address only please
Primary Contact for Billing/Administrative Matters
First Name
Last Name
Phone Number
Please enter numbers only.
Fax Number
Email
One email address only please
Authorized Case Managers/Referral Staff
Anyone who will be making referrals on behalf of your agency should be added to the list below
in order to receive their personalized referral link, including contacts who may be listed in different roles above.
We ask that you limit your referrers to no more than 5 staff. If your agency has multiple programs, then each program will need to obtain a membership with its own referrers.
Please take care to spell names and emails correctly;
any typos will result in referral links not being sent.
PLEASE NOTE: ONLY ENTER NUMBERS IN THE PHONE NUMBER FIELDS;
adding text or other characters will cause an error in receiving your referral links.
Referrer #1
First Name
Last Name
Email
Cell Phone
Please enter numbers only.
Office Phone
Please enter numbers only.
Referrer #2
First Name
Last Name
Email
Cell Phone
Please enter numbers only.
Office Phone
Please enter numbers only.
Referrer #3
First Name
Last Name
Email
Cell Phone
Please enter numbers only.
Office Phone
Please enter numbers only.
Referrer #4
First Name
Last Name
Email
Cell Phone
Please enter numbers only.
Office Phone
Please enter numbers only.
Referrer #5
First Name
Last Name
Email
Cell Phone
Please enter numbers only.
Office Phone
Please enter numbers only.
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Please attach proof of 501c3 status OR copy of Organization's 990
Contact Information
Tags
Philadelphia Furniture Bank
Philadelphia Furniture Bank
Current Member List
New Member Application
Renew Your Membership
Why You Should Join