Clothing Request Form- Work Shoes/Boots

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Use this form to submit a one-time request for slip-resistant and/or steel-toed safety footwear that is required for employment. Your request must include contact information for your employer, or you may email a copy of your employment letter to mission@coopmin.org.

Your Name (First & Last) *

Date of Birth *

YYYY

Street Address *

City, State & Zip Code

Email *

Phone *

Does the phone number you have provided accept text messages? *

Yes

Are you requesting help because of the coronavirus/COVID-19 crisis? *

Yes

Required

If "Yes", please briefly describe how the crisis has contributed to your present hardship. If “No”, enter "n/a". *

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