Thrift Store 

37B Main Street

Ludlow, VT 05149

Food Shelf

37B Main Street

Ludlow, VT 05149

 Furniture Store

105 Main Street

Ludlow, VT 05149

Hours:

   Hours:

Monday-Friday

10AM - 3PM

Hours:

Friday & Saturday

10AM - 4PM

Monday-Saturday

10AM - 4PM

Phone: 802-228-3663

Phone: 802-228-7055

2019 APPLICATION FOR HOLIDAY BASKET
Must be submitted by December 1st
(Delivery scheduled for Saturday, December 21st)

NAME_________________________________________PHONE____________________

SPOUSE/SIGNIFICANT OTHER______________________________________________

EMAIL ___________________________________________________________________

STREET ADDRESS__________________________________TOWN_________________
                                           (house number needs to be visible)
DESCIBE HOUSE AND LOCATION ___________________________________________

_________________________________________________________________________

 

HOUSEHOLD MAKE-UP: (provide number of children for each age range)

Age 1-12 ______   Age 13-18 ______   Age 19-61 ______   Age 62+ ______

(If you have a child/children under age 13 please fill out the second page of this application,                           one page for each child)

EMPLOYED:  YES ____  NO ____  WHERE: ___________________________________
SPOUSE/SIGNIFICANT OTHER:  YES____ NO ____ WHERE______________________

WEEKLY PRE-TAX WAGES:  SELF: $_________SIGNIFICANT OTHER: $_________

OTHER INCOME:
PUBLIC ASSISTANCE:  $________ UNEMPLOYMENT: $ ________    SOCIAL SECURITY: $________                REACH-UP: $_________  CHILD SUPP
ORT: $ __________ OTHER INCOME: $ ___________

EXPENSES:
RENT: $ _________  ELECTRICITY: $ _________  HEAT: $____________


FOOD PREFERENCE: (please check one)

FROZEN TURKEY (    )  FROZEN BAKED CHICKEN  (    )


SIGNATURE _____________________________________ DATE ____________________

(Black River Good Neighbor Services reserves the right to refuse any application.)