Agency Registration Form

Agencies should use the following form to register with Fresh Start Furniture Bank. After you submit the form we will review it and if we approve it, you will be allowed to submit referrals to Fresh Start. Please note that we are a volunteer based organization and that it make take a day or two to review your application. You will receive an e-mail after we have reviewed your request.

Agency name:
Address line 1:
Address line 2:
City:
State:
ZIP:
Agency phone:
Website:

The following section sets up the initial account for this agency. Additional accounts may be added later.

Referrer name:
Referrer e-mail:
Re-enter e-mail:
Referrer phone:
Referrer password:
Re-enter password: