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2020-08-26T04:38:41+00:00
Refugees Data Collection Form
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Member Code
*
Full Name (Head of Household)
*
Jama'at / Chapter
*
Gender
*
Male
Female
Phone (Cell)
*
Email
*
When did you come to United States?
*
Date
Time
How did you come to United States?
Asylum Program
Relative Sponsor
Work permit
Business Visa
Other
Street Address
*
Address Line 1
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Occupation
*
Education
*
Please describe what kind of assistance you need from the Department of Sanant-o-Tijarat?
*
Marital Status
Single
Married
Widow/Widower
Spouse's Name
Spouse Occupation
Do you have children?
*
Child Name
Child Age
Child School
Child Grade
Child Occupation
If your child is working, please state the occupation
Do you have another child?
*
Yes
No
Comment
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