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2. 
4. Referring Agency/Source Info
6. First Name*
7. Last Name*
9. Referral Organization*
11. Business Phone*
12. Cell Phone
13. Email Address*
17. CLIENT INFO
19. First Name*
20. Last Name*
21. Gender*

    1. Male
    2. Female
22. Age
    -- Select One --20-2930-3940-4950-5960+
24. Home Phone #
25. Cell Phone #
26. White Plains Resident*

    1. Yes
    2. No
28. Top Size
29. Skirt Size
30. Pant Size
32. Shoe Size
34. PLEASE NOTE
    Client must be on time to be suited. If you are late you will not be serviced. No children allowed. For questions or to re-schedule, at least 24 hours in advance, contact the WPETC at wpetc@whiteplainsny.gov or (914) 422-8200.
36. Does client need attire for a new position/employment?

    1. Yes
    2. No
38. Start Date
    Start Date
39. How many outfits are you requesting?
41. Does client need attire for an interview?

    1. Yes
    2. No
42. Interview Date
    Interview Date
44. Helpful information you’d like us to know:
Leave This Blank:


48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit

* indicates a required field