The Pantry @ OCCC Intake Form

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Your information will not be shared and will only be used for the sole purposes of administrative use and "Recall Notices" only.

Name *

Email *

Address *

Phone number. *

Household size. *

2-3

4 or more

Required

Age: *

0-17

18-59

60 & over

Check all that apply.

Required

Have you received services from ThePantry@OCCC? *

Yes

Required

Do you or anyone in your household have food allergies if so, please check all that apply.
*

Peanut Butter

Milk

Eggs

Wheat

Tree Nuts

Sesame

Fish or Shellfish

Soybean

Row 1

Anyone in the household a veteran? *

Yes

Required

What is the employment Status of household?
*

Employed (full-time, part-time)

Unemployed but looking and would like assistance.

Unemployed(student)

Retired

Acknowledgement:

The Pantry @ OCCC In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. (Not all prohibited bases apply to all programs.) To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

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