Food Pantry Intake

Services will be provided to those who live, work, or worship in Pawling. Proof of Residency is required on your first visit, for example, current utility or phone telephone bill, lease, mortgage.

Please note that by signing this application, information is subject to review and verification.

Today's Date

First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Telephone Number/Numbers

Proof of Residence, Worship or Work

Residence

Worship

Work

You will be required to provide proof of residency

How Did You Hear About Us? *

Total Monthly Household Income

Occupation/s

Employer/s and their Telephone Numbers

First Family Member (Self)

Age

Gender

If you have no additional family please fill each following line item with N/A.

Second Family Member

Age

Gender

Third Family Member

Age

Gender

Fourth Family Member

Age

Gender

Fifth Family Member

Age

Gender

Sixth Family Member

Age

Gender

If there are more members of your family, please notify us upon your first visit.

Do You Receive Public Assistance? If So What?

Reason for Coming to Food Pantry

Primary Language

Race/Country of Origin (optional, for funding purposes)

Signature – FIll in Full Name as Your Signature

Upon your first visit to the pantry, or first homebound delivery, we will ask you to fill out a TEFAP form-this is necessary for us as we need these forms for the Regional Food Bank of Northeastern New York.

Food Pantry Intake

Physical Address: 126 East Main Street,
Pawling, NY 12564
Mail Address: P.O. Box 331, Pawling NY 12564
Phone 845-855-3459
Email: info@pawlingresourcecenter.org

HOURS:
Monday-Friday 10am-4pm,
(NOW Open Wednesdays from 10 am to 5 pm)
and the 2nd Saturday of each month from 10am-12pm