Grocery Delivery Program Qualification Form

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Please complete all sections of this form to qualify to receive no cost monthly grocery delivery.

APPLICANT:

Please type out your Last name as it appears on your picture identification.

Please type in your First name as it appears on your picture Identification. *

Why do you need free grocery delivery service? Please check any that apply. *

No one in my household are available during the hours the food pantry is open

No one in my household has access to transportation to go to the food pantry

I am disabled and no one in my household can carry the food from the food pantry

I do not know where the food pantry is or how to receive food

None of the above

Required

How many Adults age 18 years of or older? *

How many children are in your household age 17 years or under? *

Based on your TOTAL number of people in your household, do you make AT or LESS than the "Annual Income" listed below *

Yes

Please check ALL that you or someone in your household currently have or receive: *

SNAP (formerly called Food Stamps)

Unemployment Recipient

Medical Assistance Recipient

TANF Recipient

Energy Assistance Recipient

Maryland Physicians Care for health insurance

None

Required

We MUST have an address to deliver your groceries. Please type out the street number and name you plan to receive groceries at and include, if applicable, your apartment, unit, or room number and/or letter: *

Please type out the name of the city or town of your address *

Please type in your zip code. *

Please type out your phone number including area code. *

Is the phone number you provided able to receive text messages? *

Yes

Do you have access to the internet from you phone? *

Yes

If you have an alternate way you would like us to send you information, please provide it here. If not, continue to next question. Such as EMAIL or FACEBOOK MESSANGER.

By checking "YES" you acknowledge that you are at least eighteen years of age and are freely allowing America's Hauling for Hope and those that volunteer for this nonprofit, permission to serve as your proxy to submit your food order to the food pantry on your behalf and deliver it to the address provided. *

Yes

Please select the option "Yes" below if you understand that this is a legally binding agreement and that all the information provided is true and that you agree to the terms presented and that your would like America's Hauling for Hope to receive and deliver your groceries.

Select option "No" If you do not agree to the terms and you do not want to receive groceries delivered at no cost from America's Hauling for Hope.

Yes

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