New Customer Registration Form

Senior Grocery Delivery Program Registration Form

We can deliver groceries to seniors in need within a 15 mile radius of 08088. Deliveries will be done on the 1st Tuesday of every month. Each delivery will have a box of pantry items, a box of produce, and a box of proteins. Deliveries are for those 60 years and older who have mobility issues.
Customer Details:

You will be notified if you are accepted into the program as there are limited amount of delivery spots available.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
I certifiy that I am over 60 years of age, in need of food, and am not able to get to the grocery store on a regular basis.

YESNO
If you are in need of food and have transportation, please visit our Mobile Food pantry on the 1st Tuesday of every month at Fawn Lake Village, 1004 Rt. 206, Shamong, NJ. Food distribution begins at 11 am.
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Senior Grocery Delivery Program Registration Form