DA BUX Access Card Request Form

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The Access Card will be mailed to the address submitted on this form within two weeks of your request. This is a free service. You may use this form to request an Access Card if you do not currently have one or your Access Card was lost or stolen. All submitted information will only be used internally for program evaluation.

Phone Number *

On which island do you reside? *

First Name of SNAP-EBT Cardholder *

Last Name of SNAP-EBT Cardholder *

First Line of Mailing Address (ex. 1234 Aloha St or PO BOX 5678) *General Deliveries will not be sent *

Mailing Address City *

Mailing Address Zipcode *

Last 4 digits of your SNAP-EBT card *

May a program staff person call you for feedback on your experience using the DA BUX Access Card? *

Yes

Please provide an email address if you would like an email receipt confirming your DA BUX Access Card request (optional).

May we contact you by email to complete a survey on your experience using DA BUX? Participation is voluntary and anonymous. Your name and contact information will not be shared and it will not be linked with your responses. Responses will be summarized and used to help improve program services. *

Yes

Thank you for signing up for a DA BUX Access Card! Your participation in DA BUX supports our local farmers and local economy, while helping you put more fresh fruits and vegetables on the table for your family!

If you have any questions about the program, please call 808-437-3044.

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