Reg No :-
E/9762/SURAT/24/11/2023
Drop a line
triplecrowncharitabletrust@gmail.com
Call experts
+91 70435-21053
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Name of Applicant :
*
First
Middle
Last
Date of Birth:
*
Gender:
*
Male
Female
Custom
Prefer not to say
Write your custom gender :
*
Marital Status :
*
Married
Unarried
Widow
Other
If other than above please specify :
*
Aadhaar number :
*
Mobile No.:
*
Email:
*
Current Address :
*
Address Line 1
Address Line 2
City
--- Select state ---
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chhattisgarh
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Odisha
Punjab
Rajasthan
Sikkim
Tamil Nadu
Telangana
Tripura
Uttar Pradesh
Uttarakhand
West Bengal
Andaman and Nicobar Islands
Chandigarh
Dadra and Nagar Haveli
Daman and Diu
Lakshadweep
Delhi
Puducherry
State
PIN Code
Residence :
*
Owned
Rented
Lease ( Geervey )
Occupation :
*
Business
Employed
Unemployed
EMPLOYMENT INFORMATION
Where do you work ?
*
Employer Mobile No. :
*
Employer Email :
Period of Current Employment :
*
Less than 6 Months
Less than 6 Months
0 - 2 Years
2 - 4 Years
4 - 6 Years
6 - 8 Years
8 - 10 Years
More than 10 Years
Job Role :
*
Sales Manager
Choice 10
Choice 9
Choice 8
Choice 7
Choice 6
Choice 5
Other
If other than above please specify :
*
Monthly Income :
*
Declaration
:
Respected Trustees / Secretary
With a due respect, I hereby declare that the detail furnished above are true
and correct to the best of my knowledge and on its basis, I would like to apply for the
Donation required for :
*
Education
Education
Medical
Marriage
Livelihood
Application Form for Medical Support
Have you ever donated blood or organs before?
*
Yes
No
If yes, please provide details:
*
Do you have any chronic medical conditions?
*
Yes
No
If yes, please specify:
*
Are you currently taking any medications?
*
Yes
No
If yes, please list them:
*
Have you undergone any surgeries in the past
*
Yes
No
If yes, please describe:
*
Do you have any allergies?
*
Yes
No
If yes, please list them:
*
Have you traveled outside the country in the past
*
Yes
No
If yes, please provide details:
*
Medical Cause :
*
Regular Monthly Medicine
Accidental Emergency
ICU cases
NICU/ Premature Babies
Cancer
Transplant
Heart Disease
Brain Surgery
Rare Disease
Multiple Organ Failure
Other Medical Treatment
If other than above please specify :
*
Patient Status :
*
He / She is at Home
He / She is at Hospital
Application Form for Educational Support
Current Level of Education
*
Primary School
Middle School
High School
Undergraduate
Postgraduate
Other
If other than above please specify :
*
Name of School / College / University / Institute :
Field of Study / Major :
*
Support Needed :
*
Tuition Fees
Books and Supplies
Accommodation
Transportation
Meals
Other
Other (please specify):
*
Current Educational Status :
*
Enrolled and Attending
On Leave of Absence
Recently Admitted
Awaiting Admission
Other
If other than above please specify :
*
Application Form for Livelihood Support
Support Needed :
*
Financial Assistance
Job Training/Education
Business Startup/Expansion
Equipment/Tools
Housing Assistance
Transportation
Childcare
Other
Other (please specify) :
Reason for Needing Support :
*
Loss of Job
Low Income
Medical Conditions
Disabilities
Single Parent
Natural Disaster
Other
Other (please specify):
Application Form for Marriage Support
Applicant :
*
Groom
Groom
Bride
Personal Information of Groom
Full Name:
*
Email Address :
Mobile Number :
Relation with applicant :
*
Myself
Myself
Guardian
Father - Son
Mother - Son
Brother - Sister
Other
If other than above please specify :
*
Have you married before ?
*
Yes
No
If yes, reason of second marriage:
*
Divorced
Divorced
Widower
Want to marry more than once
Date of Marriage
Venue of Marriage
Name of Area / Hall :
City :
Type of Marriage Ceremony :
*
Civil Ceremony
Religious Ceremony
Other
Other (please specify):
*
Personal Information of Bride
Full Name
*
Email Address :
Mobile Number :
Relation with applicant :
*
Myself
Myself
Guardian
Father - Son
Mother - Son
Brother - Sister
Other
If other than above please specify :
*
Have you married before ?
*
Yes
No
If yes, reason of second marriage:
*
Divorced
Divorced
Widower
Want to marry more than once
Date of Marriage
Type of Marriage Ceremony :
Civil Ceremony
Religious Ceremony
Other
Other (please specify):
Venue of Marriage
Name of Area / Hall :
City :
Total Expense :
*
Amount Currently Available :
*
Amount Expected to Borrow :
*
Amount Expected to Borrow (In Words) :
*
Amount already borrowed from any other means :
*
Yes
No
If yes, please provide details:
*
Submit
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