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Food Bank Application
APPLICATION

GARDINER AREA FOOD BANK – CHRYSALIS PLACE 2005

CITY OF GARDINER/SOUTH GARDINER


Applicant: __________________________________Age:       ______SS#:      ________________________                                

Address (Street):       __________________________________Tel.#:      ________________________

Address (Mailing, if different): ________________________________________________________

# in Household:____________     # Adults:       ____________    # Children:     ____________            

Names of those living with the applicant:               Age:            Social Security Number:              Relationship:

____________________________________    _____           _____________________           _______________

____________________________________    _____           _____________________           _______________

____________________________________    _____           _____________________           _______________

____________________________________    _____           _____________________           _______________

____________________________________    _____           _____________________           _______________

# in Household Employed:        _____           Where:_______________________________________________

Date receive next income:       __________________                       Amount $:     __________

Date receive next food stamps:     ____________                         Amount $:     __________

Date last used Food Bank:       ____________   Used any other Food Bank?   Y/N: ______________

If yes, when/where?     ________________________________________                                                                        
Do you own a motor vehicle(s)?  Y/N     Year   _____                     Monthly Payment:         __________                    

Monthly Expenses:       Food                Mortgage                Rent                     Electricity                        

LP Gas              Heat/Fuel               Doctor                  Other                       

I,                                              , do hereby state that the information given in this application is true to the best of my knowledge.

Applicant’s Signature:                                                  Date:                                   


Administrator’s/Asst. Administrator’s Signature:                                   Date:                        

Are you willing to volunteer at Chrysalis Place?        Yes                     No


 
 
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