FREE RECYCLED SMART PHONE

Name *

First

Last

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Age *

Ethnicity *

Gender *

Communication *

In order to understand the impact of our grants and how we can help others, please tick box so we can contact you regarding how we have assisted.

Proof of identity *

Tick box to confirm you will provide ID if selected for this project.

I hereby consent to Aishah Help using images of myself caught in video recordings, and/or photographs, taken/recorded (we will not show face if requested). *

Yes
No

i have a smartphone *

Yes
No

i have access to the internet *

Yes
No

I confirm that the information I have supplied is true and correct to the best of my knowledge. I understand that any false or undisclosed information could result in the closure of my application for assistance. *

Yes

FREE RECYCLED SMART PHONE

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