Apply EFA (Emergency Food Assistance)
Customer Details:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
Are you having an Emergency Food Crisis?
Yes
No
Are you running low on cash and need money to buy food?
Yes
No
How many people are in your household (including you)
1-2
2-3
3-4
4-5
5+
Do you need food to feed your family just for today?
Yes
No
Do you need food to feed your family for the rest of the week?
Yes
No
When is your next Snap Benefits and/or payday?
Tomorrow
Few Days
Next week
Next month
Explain. Please Specify Food Crisis
*
Are you willing to purchase only food items with gift card?
Yes
No
Maybe
Are you able to pick up gift card?
Yes
No, I’m Disabled
I have no transportation
Submit
Should be Empty: