2023 Be Connected Grocery Gift Card Form

2023 Be Connected Food Gift Card Form

For Arizona service members, veterans, and their families.
Eligibility
- Arizona resident
- Veteran or Service Member (Active Duty, Guard or Reserve) with proof of military service (Military ID, DD214, VA ID, State ID or Driver's License with veteran designation)
- Recipient must agree to a needs assessment and resource review
Program Details
- Nomination Period: Begins August 2023 until funds are depleted
- Program space is limited to the first 100 households that qualify
- Limit one gift card per household
- All food gift cards will be for $100.00
- A Be Connected team member will contact the recipient within 5-7 business days
- Upon approval, allow 5-7 business days for gift card delivery
Date of Submission*

MonthDayYear
Who are you nominating?*

MyselfSomeone Else
How were you made aware of this project?*
Nominator's Information
How are they connected to the veteran or service member? (Check all that apply.)*

Family MemberCaregiverFriend/AcquaintanceVeteran Service OrganizationBe Connected Partner OrganizationCommunity HelperOther
Nominator's Name*

First NameLast Name
Nominator's Phone Number*
Please enter a valid phone number.
Nominator's Email*
example@example.com
Nominator's Organization*
Or enter N/A (not applicable)
Please confirm the following:*

I have informed the person I am nominating and they know a member of the Be Connected team will be contacting them to participate in a needs assessment and resource review.
Please provide information about why there are current needs and how this food gift card will provide support.*
Recipient's Information

(SERVICE MEMBER OR VETERAN RECEIVING THE FOOD GIFT CARD)
Recipient's Name*

First NameLast Name
Recipient's Phone Number*
Please enter a valid phone number.
Recipient's Email
example@example.com
Recipient's Mailing Address (for delivery of grocery gift card)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Recipient's County*
Recipient's Age*
Race Category
Ethnicity
Recipient's Military Affiliation:*

Service Member (Active Duty, Guard, Reserve)Veteran (no longer serving in uniform)Retiree
Recipient's Branch of Service:*

Air ForceArmyArmy Air CorpsCoast GuardMarine CorpsMerchant MarinesNavySpace Force
Please select the preferred grocery store:*

Fry's/KrogerCostcoWalmart/Sam's ClubWhole FoodsSafeway/Vons/AlbertsonsSprouts
Please upload proof of military service.*

Cancelof
Is the recipient interested in resources/supports in any of the following areas?*

Basic NeedsEmploymentFamily & Social SupportsFinances & BenefitsHigher EducationHousingLegalMental Health & Substance UsePhysical HealthSpiritualityNone of theseOther
Thank you!

Requests are reviewed regularly and a Be Connected team member will follow up with approval status. For additional information, support or any questions, please contact the Be Connected support line at 1-866-4AZ-VETS (429-8387).
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2023 Be Connected Food Gift Card Form

Nominator's Information

Recipient's Information