2020 APPLICATION FOR HOLIDAY BASKET
Must be submitted by December 1st
(Delivery scheduled for Saturday, December 19th)

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.)
 

    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

Tuesday-Saturday

10AM - 4PM

Phone: 802-228-3663

Phone: 802-228-3663

Phone: 802-228-7055