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Gas Card Intake Form
1.
What is your name and date of birth?
2.
What is your address and phone number?
3.
What is your purpose for the gas card?
Employment
Medical Appointment
Other (please specify)
4.
If for employment please list
1. Employer name & address
2. Job title
3. Hourly pay rate
4. Hours worked per week
5.
If for medical appointment please list
1. Provider/facility name
2. Appointment date
6.
Do you receive any of the following?
SNAP (Food assistance)
Section 8/ Housing assistance
SSI/SSD
Medicaid
Medicare
Other (please specify)
Documentation
must
be provided to verify medical appointment or employment. Please be prepared to show documentation at the time of your gas card appointment. Limit of 1 gas card per household.