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2. 
3. 
5. Required Documents
7. Photo ID*
8. Proof of Residency within the City of North Miami*

   (Utility Bill, Mortgage or Credit Card Statement, etc.)

10. Applicants Information
12. Applicant's Name*
13. Email Address
15. Address*
16. City*
18. State*
19. Zip Code*
20. Phone Number*
22. Date of Birth*
23. Primary Language*
25. Please Circle:
27. Ethnicity*

    1. Hispanic
    2. Other
28. Race*

    1. White
    2. Black
    3. Native American
    4. Asian/Pacific
    5. Other
29. Gender*

    1. Female
    2. Male
    3. Prefer not to disclose
30. Marital Status*

    1. Married
    2. Single
    3. Separated
    4. Widowed
    5. Divorced
    6. Partner
32. Head of Household*

    1. Yes
    2. No
34. Other Members of the Household
36. 1. Name
37. Age
38. Date of Birth
39. Relationship to Applicant
41. 2. Name
42. Age
43. Date of Birth
44. Relationship to Applicant
46. 3. Name
47. Age
48. Date of Birth
49. Relationship to Applicant
51. 4. Name
52. Age
53. Date of Birth
54. Relationship to Applicant
56. 5. Name
57. Age
58. Date of Birth
59. Relationship to Applicant
61. 6. Name
62. Age
63. Date of Birth
64. Relationship to Applicant
66. Are you or any member(s) of your family currently receiving the following benefits/assistance?

    1. WIC (Women, Infants & Child(ren)
    2. SNAP (Supplemental Nutrition Assistance Program)
    3. MEDICAID
    4. SSI (Supplemental Social Security)

    1. TCA (Temporary Cash Assistance)
    2. FLORIDA KIDCARE
    3. None
    4. Other
68. Other
72. NoMi Food Pantry Release & Waiver of Liability Form

    By signing below and to the best of my knowledge, I certify that all information provided on this form is true and correct. I understand that the NoMi Food Pantry is a supplemental program and is not meant to replace all of my food needs.

    Resident Registrant agrees to assume responsibility for, and to indemnify, defend, and hold harmless the City of North Miami from and against any and all liability, loss, costs, and expenses, including, but not limited to attorney’s fees, claims, suits, and judgments of every kind and natures, including third party claims for indemnity, contribution, and other causes of action, whether in connection with any injury to, or death of, any person or persons or loss of or damage to any party resulting from or in any way whatsoever connected with the Resident Registrant’s or anyone else’s consumption of any food or carrying out any activities in connection with the donation and delivery of, whether or not such injury, death, loss or damage results from the partial or sole negligence for the Resident Registrant.

74. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
76. Electronic Signature
77. Date
    Date
Leave This Blank:


79. 1. Receive an email copy of this form.
80. Email address

    This field is not part of the form submission.

81. Submit

* indicates a required field