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FeedNC Pantry Application
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I am applying to be an eligible recipient to receive food at FeedNC.
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First Name
Last Name
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Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
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Gross income*
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If you are 19 or younger, please include yourself in the total.
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If you are between 19-64, please include yourself in the total.
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If you are 65 or older, please include yourself in the total.
The following person(s) are authorized to pick up my food:


I understand that any misrepresentation of need, sale, or misuse of the foods I have received is prohibited and could result in a fine, imprisonment, or both. (Sec. 211 E, PL 96-494 and Sec. 4C, PL93-86 as amended)

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Please type your full name.
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(mm/dd/yyyy)