Change Store Account

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Child's Name *

First

Last

Child’s date of birth *

Parent's Name *

First

Last

Which store would you like to shop from for food program? *

diaper Child’s to

Select which store you like to shop from for the diaper program? *

Name of person completing the application *

Declaration *

I confirm that the information provided is accurate, correct and complete and that the documents submitted along with this application form are genuine. Any incorrect or false information may result in denied application or funds owing to the City of Iqaluit to reimburse costs.

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