Name *

First Name

Last Name

I would like to see if I am elegible to receive a 40# box of shelf stable foods, plus a 2# box of cheese, on a monthly basis. *

I confirm

I confirm that I am an Ashland County resident. *

I confirm.

I confirm that I am 60 or older. *

I confirm.

I confirm that I meet the income eligibility guidlines found at the bottom of this page. *

I confirm.

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

What is your date-of-birth? *

MM

DD

YYYY

What is your race? (Mark one or more.)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White