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Citizens Data
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* Indicates required question
Name
*
Your answer
Age
*
Your answer
Does any of the below apply to you - please select one
*
Senior Citizen
Physically-challenged
Pre-existing medical condition
Mother of infant under 12 months
How often would you like assistance (please select one)
*
Once a week
Once in 15 days
Once a month
City
*
Your answer
Complete postal address (with Pin Code)
*
Your answer
Contact number (please separate multiple numbers with a comma)
*
Your answer
Which of the following would you like assistance with (please check all that apply)
*
Medicine / Medical Supplies
Groceries / Provisions
Vegetables
Meat / meat products
Pet products
Medical services (clinic / doctor)
Veterinary clinic
Gas agency
Food supply (breakfast/lunch/dinner)
Required
Are you comfortable making digital payments (UPI / PayTM, Net Banking, etc)
Choose
Yes
No
Alternate contact person
*
Your answer
Contact number of alternate contact person
*
Your answer
Comments / Additional information
Your answer
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