INTERFAITH CLOTHING CENTER                   UPCOUNTY INTERFAITH CLOTHING CENTER
751 Twinbrook Parkway                        620 East Diamond Avenue, Suite M
Rockville, MD 20351                          Gaithersburg, MD 20817
T-30l-424-3796                               T-301-977-1267
F-301-424-2724                               F-301-977-0687

                                  Referral Form

Referral agent: Client should be referred to the center corresponding to their zip code.
Clients: As of July 2002 clients will only be served at the center corresponding to their zip code.

Rockville: 20783, 20812, 20813, 20814, 20815, 20816, 20817, 20818, 20824, 20827, 20830, 20832, 20833,
20848, 20849, 20850, 20851, 20852, 20853, 20854, 20856, 20857, 20858, 20859, 20860, 20861, 20862,
20866, 20868, 20889, 20895, 20896, 20901, 20902, 20903, 20904, 20905, 20906, 20907, 20908, 20910,
20911, 20912, 20914, 20915, 20916, 20918

Gaithersburg:  20837, 20838, 20839, 20541, 20842, 20855, 20871, 20872, 20874, 20875, 20876,
20877, 20878, 20879, 20880, 20882. 20884, 20885, 20886, 21771

Please fill out the form completely. Cross out empty spaces and write your name and agency clearly.
Each family or  individual should have its own form. A new referral is needed each JuIy.

     ADULTS:
     Last Name      First Name     Initial        Social Security #   Birth Date
     _____________  ________       ____           ____-____-_____      __/ __/ ____
     _____________  ________       ____           ____-____-_____      __/ __/ ____

     CHILDREN:
     Last Name      First Name     Initial        Sex            Birth Date
     _____________  ________       ____           ___            __/ __/ ____
     _____________  ________       ____           ___            __/ __/ ____
     _____________  ________       ____           ___            __/ __/ ____
     _____________  ________       ____           ___            __/ __/ ____

     
Client's address including zip code:________________________________________________
____________________________________________________________________________

These clients are residents of Montgomery County and are in need of free clothing and household items.

Referring Agency:_____________________________________________ Date: _____________
Address: _______________________________________________________________________
Phone and Fax: __________________________________________________________________
Printed Name and Signature: _______________________________________________________


o  Client hours: Rockville.: Monday, 2:30 p.m.-5:3O p.m., Thursday, 9:00 a.m.-1:30 p.m., Saturday, 12:30 
p.m.-2:30 p.m. and Clients with disabilities  - Wednesday, 11:30 a.m.- 1:00 p.m. 
Gaithersburg: Wednesday, 9:30 a.m.-2:30 p.m., Saturday, 11:00 a.m.-2:00 p.m.
o  Open year round except for the first two weeks of July, the last week of December, Federal 
Holidays, Yom Kippur, and Thanksgiving Saturday.
o  Clients must bring identification, proof of current Montgomery County address and Social
Security Number for all adults who have one.