Food Pantry Intake -

Services will be provided to those who live, work, or worship in Pawling. Proof of Residency is required on your first visit, for example, current utility or phone telephone bill, lease, mortgage.

Please note that by signing this application, information is subject to review and verification.

Date *

Your Name *

Spouse or Domestic Partner *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Telephone Number/Numbers *

(If we are unable to contact you by phone, we may refuse service)

Email *

Proof of Residence, Worship or Work *

Residence
Worship
Work

You will be required to provide proof of residency

How Did You Hear About Us? *

Total Monthly Household Income *

Occupation/s *

Employer/s and their Telephone Numbers *

First Family Member (Self) *

First

Last

Age *

Gender *

If you have no additional family please fill each following line item with N/A.

Second Family Member *

First

Last

Age *

Gender *

Third Family Member *

First

Last

Age *

Gender *

Fourth Family Member *

First

Last

Age *

Gender *

Fifth Family Member *

First

Last

Age *

Gender *

Sixth Family Member *

First

Last

Age *

Gender *

If there are more members of your family, please notify us upon your first visit.

Do You Receive Public Assistance? If So What? *

Reason for Coming to Food Pantry *

Primary Language *

Race/Country of Origin (optional, for funding purposes)

Signature – FIll in Full Name as Your Signature *

Upon your first visit to the pantry, or first homebound delivery, we will ask you to fill out a TEFAP form-this is necessary for us as we need these forms for the Regional Food Bank of Northeastern New York.