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* 1. Name:

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* 2. Location or address:

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* 3. Contact number:

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* 4. Email address:

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* 5. Household type:

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* 6. Number of children

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* 7. Age of child or children:

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* 8. How much funds are needed:

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* 9. What are the funds needed for: i.e. school camp, uniform

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* 10. Would you be interested in applying for a no interest micro loan:

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* 11. If you would like any further information please write below:

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