Angel Food Ministries EBT Order Form

Card Holder Information:

Name as it appears on card

*First Name *Last Name

*Address 1

Address 2

*City *State *Zip

*Phone

Email Address

*Food Stamp Card Number (Begins with 5077 0200)

*Date money is deposited to your EBT/Food Stamp account (mm/dd/yyyy):
*indicates required field

I authorize I do not authorize Bookwalter United Methodist Church to withdraw funds from my EBT account (Food Stamps) and sign the receipt on my behalf. Also I understand any orders not picked up at the set time will be redistributed at Bookwalter UMC's discretion without refunds or credits. I agree to the terms and conditions of using this online form to submit information regarding my August 2010 Angel Food Order and that my order is not complete until I receive an email or verbal confirmation.