SELF REFERRAL HAMPER APPLICATION

SELF REFERRAL HAMPER APPLICATION
DATE *

Month Day Year
Date
Main Contact LAST NAME *
Main Contact FIRST NAME *
Main Contact AGE *
Main Contact STREET ADDRESS *
Main Contact DAYTIME PHONE *
Is it ok for us to leave a message at this number? *

Yes No
Dietary Concerns: *
SUGGESTED GIFT IDEA: Main contact (MAX 2) *
GOVERNMENT ISSUED ID FOR MAIN CONTACT IS REQUIRED IN ORDER TO RECEIVE HAMPER. BANK STATEMENTS AND RECEIPTS MAY BE ASKED FOR AS INCOME VERIFICATION.
Government ID & other documents are required for verification *

Yes, I understand and agree
Are there additional people living with the applicant? *

Yes (please list them all below) No
Personal information on this form is collected under the authority of the Freedom of Information and Protection of Privacy Act, Section 33CRSA If you have any questions regarding the collection or use of this information, please contact the President or Vice President of The Airdrie 1st Club at 403-660-1569 email: info@lairdrieist.com
PLEASE LIST ALL OTHER INDIVIDUALS LIVING WITH APPLICANT
Additional Individual #1 Name

First Name Last Name
Additional Individual #1 AGE
SUGGESTED GIFT IDEA: Additional Individual #1 (MAX 2)
Additional Individual #2 Name

First Name Last Name
Additional Individual #2 AGE
SUGGESTED GIFT IDEA: Additional Individual #2 (MAX 2)
Additional Individual #3 Name

First Name Last Name
Additional Individual #3 AGE
SUGGESTED GIFT IDEA: Additional Individual #3 (MAX 2)
Additional Individual #4 Name

First Name Last Name
Additional Individual #4 AGE
SUGGESTED GIFT IDEA: Additional Individual #4 (MAX 2)
Additional Individual #5 Name

First Name Last Name
Additional Individual #5 AGE
SUGGESTED GIFT IDEA: Additional Individual #5 (MAX 2)
Additional Individual #6 Name

First Name Last Name
Additional Individual #6 AGE
SUGGESTED GIFT IDEA: Additional Individual #6 (MAX 2)
Additional Individual #7 Name

First Name Last Name
Additional Individual #7 AGE
SUGGESTED GIFT IDEA: Additional Individual #7 (MAX 2)
Please list out additional family members last name, first name, age and gift suggestions for any more members
Should be Empty:

SELF REFERRAL HAMPER APPLICATION

GOVERNMENT ISSUED ID FOR MAIN CONTACT IS REQUIRED IN ORDER TO RECEIVE HAMPER. BANK STATEMENTS AND RECEIPTS MAY BE ASKED FOR AS INCOME VERIFICATION.

PLEASE LIST ALL OTHER INDIVIDUALS LIVING WITH APPLICANT