Giving to the Nations  –  devoted to advancing the lives of others

Please complete the Intake Form online or download, print and return to us through email or US Mail (instructions are on the form).

Downloads: Intake Form  | Product List

Giving to the Nations - Client Intake Form

OFFICE USE ONLY

Date : _______________    | Request Type: Individual | Event / Name ____________________________

New Client Certification | Client Recertification | Client Number: ____________________

Processed By: _____

Please fill out the entire form so that we may serve you better

NOTE: These questions do not determine your ability to receive services.  This information is collected for tracking the need for future services and for obtaining additional funding to support our programs.

CLIENT DOCUMENTATION

 

CLIENT INFORMATION

 

Household Information

How many people live in your house in the following age/gender groups and indicate how many are male or female


PETS - Please enter a number for each.

MILITARY STATUS


PLEASE SELECT YOUR RACIAL CATEGORY

Please select all that apply*


PLEASE SELECT YOUR ETHNIC CATEGORY

Please select all that apply*


DOES YOUR FAMILY RECIEVE ANY TYPE OF ASSISTANCE?

Please select all that apply*


Household Income*

These questions do not determine your ability to receive services. 

Please list each family member receiving income.


Acknowledgement and Signature


CLIENT ACKNOWLEDGEMENT

I certify that I am a member of the household listed above, 18 years of age or older, and certify that all information regarding my household is true to the best of my knowledge.  I also designate the following person(s) as an authorized representative(s) of my household and certify that their information is correct to the best of my knowledge.  Authorized representative(s) is/are able to pick up product for client until re-certification is necessary.


This section is only necessary if someone will be picking up product for you.

If you will be picking up for yourself, please leave this blank.

Name of Authorized Representative(s)

Authorized Representative(s) Address/Phone

All applicants MUST sign this form digitally.

NOTE: These questions do not determine your ability to receive services.  This information is collected for tracking the need for future services and for obtaining additional funding to support our programs.

(office use only)

Pick up Person: _______________________________________________________   Pick up Date: __________________

 
 

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