Name *

First Name

Last Name

Phone *

(###)

###

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Delivery or Pick-up *

NCHW can support 50 local deliveries per month. If you are in the Plattsburgh area and able to, we ask that you select pick-up. Pick-ups are at 90 Sharron Ave in Plattsburgh.

Delivery

Pick-up

Do you receive government assistance? *

Yes

No

Allergy Waiver *

North Country Health and Wellness will make reasonable efforts to accommodate food allergies. Due to the volume of food packages we create, there is a risk of cross contamination. North Country Health and Wellness Inc assumes no responsibility for any injury, sickness, etc that occurs .

I understand