Please use this form to apply for your Foodtown Preferred Customer Club Card.

Fill out the application. Click on the "Send Application to Nicholas Markets" button at the bottom of the page. The form will then be emailed to our main office. You will receive your New Foodtown Preferred Customer Club Card in the mail within 2 to 3 weeks.

Please Note: All items marked with a "*" are required and must be filled in before your application will be sent. If you wish to have check cashing privileges you must fill out the bottom section of this form.

* Applicant's First Name	M.I.	* Last Name
* Social Security Number		* Home Phone
* Store Location Where You Shop Select Store Shopping Location Cedar Grove Haledon North Haledon Paterson
* Date of Birth
* Mother's Maiden Name

* Street Address & Apt. No. if applicable (No P.O. Boxes, please)

* City

* State Select State NJ NY CT PA

* Zip + 4 +

* E-mail Address

Please answer the following questions so that we may serve you better.

1. Number of Children D.O.B. -	D.O.B. -
D.O.B. -	D.O.B. -

2. Do you have pets?

No Yes

Your privacy is extremely important to us here at Nicholas Markets. Because your patronage to Nicholas Markets is important, we promise never to reveal confidential information about you to outside sources, ever. Nicholas Markets will record your purchases when you use your Preferred Customer Club Card. By doing so we will be able to offer you, the customer, special offers, coupons, special priveleges and other information of value to you. Once again thank you for your loyalty to Nicholas Markets. I do not wish to receive coupons, special offers or other information.

Required information for check cashing privileges. Returned checks are subject to a fee as posted in the store. See store policies.

Applicant's Driver's License No.

State Select State NJ NY CT PA

Employer's Name & Address

Business Phone

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