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Pickup Request Form

First Name:

Last Name:

Organization:

Email Address:

Phone Number:

Street Address of Pick-up Location:

City:

Postal Code:

Nearest Major Intersection:

Contact Name at Pick-up:

Contact Phone Number at Pick-up location:

Special Instructions for Driver:

Requested Pick-up Date (DD-MM-YYYY):

How Much Food Do You Have? (ie. size and number of bags or boxes)

Do you also have a monetary donation to be picked up? Yes No

If yes, what is the amount?