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Foodbank of the Virginia Peninsula Connect Sign up Form

Fields marked with a (*) are required

Is this an update/correction to a previous submission?: (*)
Please Chose YES or NO
Users First Name (*)
We need your FIRST NAME
Users Last Name (*)
We Need your last name
Agency Foodbank Account Number (*)
Must include Assigned foodbank member number.
Assigned foodbank member number.
Agency Name (*)
Agency Name is required
The FULL name of your organization
Street Address (*)
Need a Street Address
City (*)
Please add a value for City.
Zip (*)
Need Zip Code
Password (*)
Need password
Password you would like to use for your account. Password can be no less than 4 Characters &/or numbers.
Confirm Password (*)
Need password
Users Telephone (*)
Please Fill in the users telephone number. in the form of ###-###-####
The telephone number of the user assigned this account.
Users Email Address (*)
is not a valid e-mail address.
Confirm Email Address (*)
Need valid Email Address
You must agree to the site Terms of use before proceeding.
I understand that the following account is subject to the terms of use of this site
and will remain active based on organization membership to the foodbank,
MF account status, or until I notify the Foodbank of the Virginia Peninsula otherwise.

(*) Electronic Signature and Authorization

Please add a name for Authorization.
(Person Authorizing the Signup) verify that the above information is being submitted in truth and is correct. I understand that this user account is to ONLY be used by the assigned user stated herein. I authorize the Foodbank of the Virginia Peninsula, to grant access to the user listed above to the foodbank member agency collaboration extranet (Connect) on behalf of our organization.