Christmas Food Basket Registration Form

Helps charitable organizations collect household and income information from families requesting a holiday food basket.

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Full Name

First Name

Last Name

Email Address

Contact Number

Home Address

Street Address

City

State / Province

ZIP / Postal Code

Number of people in your household

Annual income of your household ($)

Primary source of income

Employment Government Assistance Retirement/Pension Other

Number of Females

Number of Males

Ages of people in your household

First Name

Last Name

Date

Signature

Sign here

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