Cimarron Food Delivery Request Form

Cimarron Food Delivery Request Form

In Partnership with
Please fill out this form to request a food delivery. This form is for Cimarron resident use only. Once we receive your request, we will coordinate a delivery to your home in coordination with the Cimarron free food distribution events. Please submit your requests by Friday at 9:00 a.m. for Monday delivery.

Deliveries will occur every other week on Mondays between 3:30-5:00 pm. Upcoming dates are:
- May 2
- May 16
- No distribution May 30th
- June 13
- June 27
If you would like deliveries on a different date, please submit a request to: http://www.bit.ly/foodshelfdeliverymn

Contact foodshelfdeliverymn@gmail.com or 651-390-6507 with questions.
Name *

First Name Last Name
Enter an Address *
Delivery instructions: Is there a gate or access number needed to enter?
Phone Number *
Alternate Phone Number
Email
example@example.com
How often would you like a delivery? Please note: your order must be received by 9 a.m. the Friday before the delivery. *

One time Every other week
Please indicate if you prefer a specific dietary option or an additional item in your pack:

Gluten Free Vegetarian Dog Food Cat Food Diapers
If you selected diapers, please indicate what size:
How many people in your household are children (ages 0-17)? *
How many people in your household are adults (ages 18-64)? *
How many people in your household are seniors (age 65+)? *
By submitting this form, I understand that I am voluntarily providing private information about myself. I understand I am not required to provide this data but if I do not I will not be able to have essential goods delivered to me. I understand and agree my data may be shared with providers of delivery of essential goods, persons that I give written consent and as required or authorized by law.
Should be Empty: