Free School Supply Application Limited to Residents of Morris and Passaic County, NJ and Kankakee County, IL* Parent's Name Address City State Zip Day Phone Parent's Email Address (required) Family Income Both Parents Employed? Yes No Was student born in USA? Yes No Student Nationality African American Caucasian Hispanic Native American Other Student's Name Current School School District County Most Recently Completed Grade Comments About Request   If you are uncomfortable emailing this information to us as we do not yet have SSL protection, print this out and fax it to us at 707-371-7037 or mail it to the address below. NOTE: Information is kept confidential. Not all applicants will be approved/accepted. We will contact you in early August via phone or email to notify you if you have been accepted to receive free school supplies for the upcoming school year. Deadlines for Fall 2003 submission is July 31st. *We cannot ship goods so we have to limited the school supplies for the areas indicated above.

Focus America, A NJ Non-Profit Corporation
PO Box 267, Convent Station, NJ 07961
Phone: 862-812-0548 * Fax: 707-371-7037
info@focusamerica.org
Copyright 2002-2005. All Rights Reserved.

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