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Form: Retail Pick Up Form
Agency Name
*
G041 St. Martin
H288 God's Grain Bin
J265 CFS Portland
M004 Helping Hands
M120 Elwood Community Pantry
M192 Park Place
M259 Chesterfield
M299 South Madison Food Pantry
R215 Winchester Area
W210 Living Well Wabash
I have a Scale
*
Yes
No
If you are weighing your own items, enter "yes", if you are counting your items, enter "no". It helps a lot with our calculations.
Retail Store Name
*
WalMart
Aldi
Kroger/PayLess
Meijer
Target
Ruler Foods
Fresh Thyme
Needlers
Store #
*
List Items Here
Please enter the number of boxes you receive of each item in the appropriate boxes. If you have multiple pick-ups from the same location, press the (+) sign to add a new entry for each different date. The total weight will be calculated automatically.
Pickup Date
Bakery
Meat
Produce
Deli
Dairy
Frozen Grocery
Dry Grocery
Non-Food
Add
Remove
List Item Weight Here
Please enter the pounds you receive of each item in the appropriate boxes. If you have multiple pick-ups from the same location, press the (+) sign to add a new entry for each different date. The total weight will be calculated automatically.
Pickup Date
Bakery
Meat
Produce
Deli
Dairy
Frozen Grocery
Dry Grocery
Non-Food
Add
Remove
Hidden
Bakery
Hidden
Meat
Hidden
Produce
Hidden
Deli
Hidden
Dairy
Hidden
Frozen Grocery
Hidden
Dry Grocery
Hidden
Non Food
Agency Contact Email
*
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Your ticket for the: Form: Retail Pick Up Form
Title
Form: Retail Pick Up Form
USD
