Community EBT Grocery Delivery Program

Customer Application & EBT Authorization

Customer Information

Name

Phone Number

Date of Birth

Social Security Number

Case Manager (optional)

Mailing / Delivery Address

Address Line 1

Address Line 2

Address Line 3

Address Line 4

City

State

ZIP

Identification

Do you have a valid ID?

Yes

Upload your valid ID (optional)

JPG, PNG, WEBP, HEIC, or PDF. Max 10MB. You can take a photo with your phone.

SNAP / EBT

Do you currently receive SNAP / EBT?

Yes

Food Package

Select your preferred food package

Standard

Vegetarian

Other

EBT Authorization

I authorize the Community EBT Grocery Delivery Program to process a recurring purchase of $70 per week from my SNAP/EBT account for grocery deliveries. I understand this authorization remains in effect until canceled by me or the program.

I agree to the EBT authorization above and authorize the recurring $70 weekly purchase.

Participant Signature

Sign your full name below

Sign here with your finger or mouse