Applicant Name (First and Last) * Address * Home Phone: Cell Phone: Email address: * Select preferred contact method home phonecell phoneemail Number of Family Household Members: * By requesting this assistance, I acknowledge my Branford residency and my need status due to the COVID-19 pandemic event. Upon acceptance, I understand the gift cards will be mailed to the above address. By signing below, I hereby certify the information in this application is truthful and accurate and I accept the program guidelines. Signature and Date: * For Internal Use Only Gift Certificate # Restaurant: Amount:
