Please note: In order to receive a delivery, you must complete this form and receive an approval notice from us. Until you receive that notice, we cannot guarantee your delivery.

A few important things to know:

• Completing this form helps us to understand your household needs—but does not automatically guarantee delivery.

• We review each application carefully, without regard to race, color, national origin, age, sex (including gender identity), disability, religious creed, marital status, or any other protected characteristic.

• We welcome and encourage everyone to apply; we are committed to treating all applicants with dignity and respect.

• If you have questions or need assistance filling out this form, please let us know and we will gladly help.

Thank you for taking the time to fill out this form for us so we can provide you with the care that you need.