Submit a Member Agency Application

New Member Agency Application for FY26 (July 1, 2025 to June 30, 2026)

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

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

Cell Phone

Please enter numbers only.

Office Phone

Please enter numbers only.

Referrer #2

First Name

Last Name

Cell Phone

Please enter numbers only.

Office Phone

Please enter numbers only.

Referrer #3

First Name

Last Name

Cell Phone

Please enter numbers only.

Office Phone

Please enter numbers only.

Referrer #4

First Name

Last Name

Cell Phone

Please enter numbers only.

Office Phone

Please enter numbers only.

Referrer #5

First Name

Last Name

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

Submit a Member Agency Application

Philadelphia Furniture Bank