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Southeast Arkansas College Food Pantry Application
*Must present SEARK ID at time of pick up*
General Information:
First Name: ___________________________ Last Name: ____________________________________
SEARK ID Number: _______________________ Phone Number: ________________________________
Address: ____________________________ City/State: ____________________ Zip Code: ___________
Date of Birth: ________________________ Veteran: Yes No (Please circle one)
Please circle one: Can you accept refrigerated/frozen food items:
Student Staff Faculty Yes No
Household Information:
Please list the name and ages of ALL persons in your household (including yourself):
How many people in your household are currently employed? _______
Acceptance of Free Food and Waiver of Liability:
By my signature, I acknowledge the receipt of free food from the Southeast Arkansas College Food
Pantry. I understand this is a gift and not a reoccurring obligation by Southeast Arkansas College.
I further understand and agree that by accepting this donated food I freely and voluntarily, with full
knowledge, hold harmless and in no way liable Southeast Arkansas College, its officers, agents,
employees, students, donors, volunteers, and food suppliers for the quality, condition or packaging of
the food.
Printed Name: ______________________________
Signature: __________________________________ Date: _______________________________
Please return the completed form to the Career Pathways office (College Hall, Office 112/113)
INTAKE INITIALS: ______________ DATE: __________________
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