Florida Department of Agriculture and Consumer Services
Division of Food, Nutrition and Wellness
SPECIAL MILK PROGRAM
ADAM H. PUTNAM
SITE APPLICATION
COMMISSIONER
Section 595.404, Florida Statutes; 7 CFR Part 215
SCHOOL YEAR - 20___ - 20____
Sponsor Number_______________________________________________________________________
Site Number __________________________________________________________________________
Site Name ____________________________________________________________________________
Site Physical Address ___________________________________________________________________
Address 2 ____________________________________________________________________________
County____________________________ City ___________________________Zip Code ____________
Site Information
Site Type (choose one)
Public School
Private School
Camp – Summer
Public RCCI
Public RCCI/Public School
Private RCCI/Private School
Camp - Year round
Charter School - Charter School Agreement Expiration Date _______________
Site Officials
Site Contact
Position/Job Title______________________________________________________________________
First Name ________________________________________________ Middle Initial ________________
Last Name____________________________________________________________________________
Email ____________________________________________ Fax Number__________________________
Phone Number ____________________________________ Extension____________________________
FDACS-02014 06/15
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Florida Department of Agriculture and Consumer Services
Division of Food, Nutrition and Wellness
SPECIAL MILK PROGRAM
ADAM H. PUTNAM
SITE APPLICATION
COMMISSIONER
Section 595.404, Florida Statutes; 7 CFR Part 215
SCHOOL YEAR - 20___ - 20____
Sponsor Number_______________________________________________________________________
Site Number __________________________________________________________________________
Site Name ____________________________________________________________________________
Site Physical Address ___________________________________________________________________
Address 2 ____________________________________________________________________________
County____________________________ City ___________________________Zip Code ____________
Site Information
Site Type (choose one)
Public School
Private School
Camp – Summer
Public RCCI
Public RCCI/Public School
Private RCCI/Private School
Camp - Year round
Charter School - Charter School Agreement Expiration Date _______________
Site Officials
Site Contact
Position/Job Title______________________________________________________________________
First Name ________________________________________________ Middle Initial ________________
Last Name____________________________________________________________________________
Email ____________________________________________ Fax Number__________________________
Phone Number ____________________________________ Extension____________________________
FDACS-02014 06/15
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Approving Official for free milk
Position/Job Title______________________________________________________________________
First Name ________________________________________________ Middle Initial ________________
Last Name____________________________________________________________________________
Email ____________________________________________ Fax Number__________________________
Phone Number ____________________________________ Extension____________________________
Hearing Official for free milk
Position/Job Title______________________________________________________________________
First Name ________________________________________________ Middle Initial ________________
Last Name____________________________________________________________________________
Email ____________________________________________ Fax Number__________________________
Phone Number ____________________________________ Extension____________________________
Verification Official for free milk
Position/Job Title______________________________________________________________________
First Name ________________________________________________ Middle Initial ________________
Last Name____________________________________________________________________________
Email ________________________________________________________________________________
Phone Number__________________________ Extension_____________ Fax_____________________
The Approving Official must be a Sponsor employee, not a FSMC employee and must be different than
the Hearing Official. Hearing Official(s) must not be connected to the application or verification
processes and may not be an FSMC employee. Verification Official (s) must be a Sponsor employee, not
an FSMC employee, and must be different than the Hearing Official.
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Participation Information
Days of the week milk is served and claimed for reimbursement
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Months of Operation
January
February
March
April
May
June
July
August
September
October
November
December
Will meals be claimed by grade or age?
Grade
Age
Grades Claimed at this site (check all that apply)
Infants
Pre-Kindergarten
Kindergarten
1-12 (check all that apply below)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Ages claimed at this site (check all that apply)
0-4
5-20 (check all that apply below)
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Is milk being claimed at this site for another site?
Yes
No
If Yes, provide the site name and site number
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Collection Procedures for milk
Prepay
Part of Tuition
No Charge
Counting procedures for milk
Automated/Computerized system
Cash register
cash register and roster
Clicker (counting/claiming in one category)
Electronic device (e.g. wand, pen/roster)
ID card
Roster
Tally sheet
Current Free Enrollment
Current Paid Enrollment
Total
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