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APE- Online Distribution of Ebola Buckets
Apply to receive a bucket, and soap package from the NRRI. Note that only those with three family or group members above are allow to apply for a Bucket.
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* Indicates required question
Applicatant Name
*
Your answer
Phone numbers
Your answer
Have you or your family member had Ebola before?
No
Yes
Other:
Clear selection
Have you received Ebola Bucket from another organization before?
Yes
No
Total number of family members
*
1
2
3
Other:
Why do you need a Bucket?
Your answer
Community Name
Rehab community
RockHole, ELWA Community
ZubahTown Dupo Raod
ZinnahHill, GSA Road
ThinkersvilleRIA Highway
Clear selection
How do you feel about the Ebola Crisis in Liberia?
Your answer
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