Furniture Depot
Referral / Goods Distribution Form
Store: 66 Mechanic St. (corner Lincoln St.), Marlborough, MA 508-485-2080
Please Note: Goods Will Not Be Distributed Unless Form Is Completed In Entirety
Customer Name:
Customer Address:
Customer Phone:
Total Number in Household:
Total Youths in Household:
Referring Agency:
Referral Source Contact Name:
Referral Date:
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Critical Items
Needed:
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Living Room
Kitchen
Referral Source Phone:
If customer wishes to self-identify race/ethnicity
Please add here:
Bedroom
Other
Referral Source Email Address:
Initial Customer
Visit Date:
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Referral Close Date - Up to 1 month from initial
visit.
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Items Selected
# Bags/Boxes Small Items:
Customer Pickup Date
Date Taken from Store
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Comments
Customer Signature: _____________________________________
Date:
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(Signature indicates items have been / will be picked up according to agreement)
TouchStone Furniture Depot (a non-profit, charitable 501-C3 organization), receives donated furniture/household items and distributes them to needy families and individuals referred by qualified
social-service agencies and other professionals.
F.O. Volunteer: ______________________________