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Mail-A-Meal Box Request Form
Mail-A-Meal Box Request Form
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* Indicates required question
Name
*
Your answer
Full Mailing Address
*
Your answer
Phone Number
*
Your answer
Email
*
Your answer
Total # of
children age 17 or younger
in your household
*
Your answer
Total # of
adults age 18 to 59
in your household
*
Your answer
Total # of
seniors age 60 or over
in your household
*
Your answer
To get to a full-service grocery store, I usually travel ____ miles. (example: Albertsons)
*
Your answer
Do you have regular or reliable transportation?
*
Yes
No
Will a monthly Mail-A-Meal box help make it possible to afford other important household expenses?
*
Yes
No
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