HEAVENS

GATEWAY MINITRIES INC.

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Heavens Gateway Ministries

9517 S Main St

Jonesboro, GA 30236

(678) 545 4785

heavensgateway1@yahoo.com

Heavens Gateway Ministries
Guest Intake Form

First Name

Middle Name

Last Name

Email

Phone

Homeless?

Yes

No

Total Individuals:

How many individuals in this household are between ages 0 and 17?

How many individuals in this household are between ages 18 and 59?

How many individuals in this household are over 60 years of age?

Address

City/Town

State/Province

Zip/Postal Code

Gender

Date of Birth

Nationality/Race

Marital Status

Reasons for food assistance:

How did you hear about us?

How many Single Adults in the household?

Senior Raising Grandchildren

Veteran?

YES

NO

Disabled?

YES

NO

Vegan (Y/N)

Income Salary (Financial Help)

PLEASE HAVE YOUR IDENTIFICATION READY! THANK YOU IN ADVANCE

Successful Submission

ABOUT US

Heavens Gateway Ministries, Inc. is a 501 (c) (3) nonprofit organization established 12 years ago, South of Atlanta in Jonesboro, GA. We operate a Community Food Bank and a Clothes closet that currently serves over 6000 low-income and unemployed families.

ADDRESS

678-545-4785

9517 South Main Street

Suites 200 - 400

Jonesboro Georgia 30236

heavensgateway1@yahoo.com

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