Food Assistance Pickup Authorization

Food Assistance Pickup Authorization
Authorize another individual to pick up food assistance on your behalf. Please complete all required information accurately.
Recipient's Full Name
First NameLast Name
Recipient's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Recipient's Email Address
example@example.com
Recipient's Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Authorized Person's Full Name
First NameLast Name
Authorized Person's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Person's Email Address
example@example.com
Date of Pickup
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Type of Food Assistance to be Picked Up
Reason for Authorization
Additional Notes or Instructions
Recipient's Signature
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