Citizens Data
Name *
Age *
Does any of the below apply to you - please select one *
How often would you like assistance (please select one) *
City *
Complete postal address (with Pin Code) *
Contact number (please separate multiple numbers with a comma) *
Which of the following would you like assistance with (please check all that apply) *
Are you comfortable making digital payments (UPI / PayTM, Net Banking, etc)
Alternate contact person *
Contact number of alternate contact person *
Comments / Additional information
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