Applicant First Name:

Applicant Last Name:

Phone (xxx-xxx-xxxx):

Email Address:

Date of Birth (MM-DD-YYYY):

Mailing Address Line 1:

Apt / Suite:

City:

State:

County:
Clark

Zip Code:

Do you meet ALL of the above requirements?
YesNo

If you have a SFMNP benefit card from last year (2023), you may be able to re-use it for this season. Please enter the last 6 numbers from your 2023 WA-SFMNP benefit card in the space below (optional):

Do you consider yourself Hispanic/Latino:
YesNo

Please check all that apply:
American Indian or Alaska NativeAsianAfrican AmericanCaucasianNative Hawaiian or Other Pacific IslanderNative America

Do you use a smart device, such as a cell phone or tablet?
YesNo

Do you have access to reliable internet?
YesNo

The SFMNP Mobile App allows you to access your SFMNP benefit information, purchase history, and find local vendors. Are you interested in downloading this app?
YesNo

In which language would you prefer to receive information? Please select one only:
AmharicCambodianChineseEnglishKoreanLaotianRussianSpanishSomaliTagalogTigrinyaUkranianVietnamese

Are you completing this form on behalf of an eligible applicant?
YesNo

First Name:

Last Name:

Agency or Affiliation:

Phone Number:

Email Address:

By clicking “submit”, I acknowledge the information entered above is true and correct. I agree to enter one affidavit per person. I also acknowledge my submission may be put on a waitlist or denied if deemed a duplicate, invalid information or address, or I do not meet the qualifications listed above.
YES, I AGREE