Survey - Get Help - Second Harvest Heartland

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Question - Required - Name:

Question - Not Required - Phone number:

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Question - Required - Email:

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Question - Required - What city do you live in?

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Question - Required - What is your zip code?

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Question - Required - Which county do you reside in?

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Question - Required - Do you have an interest in a particular program? Please check all that you are interested in.
Please make at least 1 selection from the choices below.

	Supplemental Nutrition Assistance Program (SNAP)
	Commodity Supplemental Food Program (CSFP) for seniors

Question - Not Required - Other comments you would like us to know?

(Maximum response 255 chars, approx. 5 rows of text)

Why are we asking this information? Answering these questions will help us determine what programs you are eligible for. With whom may we share information? We will only share information about you as needed and as allowed or required by law.

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