Food Application Form ~ Bountiful Community Food Pantry
480 East 150 North, Bountiful, Utah Mon. – Fri. 11am. – 1pm., Tues. Wed. Thurs. 6pm-8pm, Sat. 10am-Noon
Resident of Bountiful, Centerville, Farmington, North Salt Lake, West Bountiful & Woods Cross ONLY
Last Name: __________________________ First Name: __________________________ TODAY’S DATE: ______________
Address: ____________________________ City, State, Zip: _____________________________________________________
Phone Number: __________________________________________________________________________________________
A. Family member information (including your information)
First & Last Name
Birth Date
MM/DD/YYYY
Employed
Yes or No
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
B. Combined GROSS income of everyone in household: $________per month
C. Is anyone authorized to pick up food for you? (If so, please circle one) YES or NO
Name of person who you want to pick up food:________________________________
D. Total number of family members living in your household (do not include unborn
Children or temporary guest): ________________
E. Family Ethnic background (please circle one):
Native American, Hispanic, African American, Asian/Pacific Islander, Caucasian, Other
F. Head of household statistics (please circle one):
Single Parent with children, two parents with children, single person, two people, other
Pantry Use Only
Check when completed
□Birth certificates, Proof of residency
Income verification & photo ID checked at
first visit? Also inform applicant they
must show photo ID at every visit.
□Income verified (SS, Disability, pay stub,
Child support, other, or signed unemployed
Form)
□Resources discussed
□New Card issued Card Number:_________
□Date issued________________
□Information checked by:________________
□Application & volunteer signed the back
(Hold Harmless Statement)
□Applicant lives in Centerville, Bountiful,
Farmington, West Bountiful, Woods Cross,
North Salt Lake. If the applicant lives
Outside of this area, they MUST go to
Another food pantry.
□Entered into the computer