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*Please note that we are cannot process incomplete forms, so kindly ensure that your form is filled out completely and accurately

Are you requesting a food pickup or delivery?
Pickup
Delivery

Head of Household Information

Date of birth
Month
Day
Year
Type of phone
Home
Cell
Work
Primary Language
English
Spanish
Decline to answer
Other
Multi-line address
Race
Native American Indian or Alaskan Native/Natural Indio o de Alaska Americano Nativo
Asian/Asiático
Black/African American/Americano Negro/ Africano
Native Hawaiian or Pacific Islander/Isleño Hawaiano o Pacifico Nativo
White
Other/Otro
Declined to answer
Ethnicity
Hispanic/Hispánico o Latino
Non-Hispanic/No Hispánico o Latino
Other/Otro
Declined to Answer

Household information

Please list the name, age, and gender for EACH household member, including yourself.

Are you or a member of your household in the military or a veteran?
Yes
No
Are you currently employed?
Full time
Part time
Not employed
Prefer
Are you currently receiving any of the following benefits?
Is your delivery address the same as the address listed above?
Yes
No
Please review the chart below and choose if your total household income (not just your income) is ABOVE or BELOW the income listed for your household size.*

I certify that all the information I provided is true and accurate

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