Wheelchair Application Form

Beneficiary Information Form

Wheelchair Distribution Project — Muslims for Humanity

Basic Information

Upload Full Body Photo

Full Body Picture *

Full body picture is required.

Apply For *

Self

On behalf of a beneficiary

1 Full Legal Name (According to CNIC) *

Disability *

Please select disability type.

Age * 1 – 120

Gender *

Please select gender.

Nationality *

2 CNIC Number * Sirf digits enter karein — dashes auto lag jayenge

3 Contact Information

Primary Phone *

Alternate Phone

Email Address *

4 Address Information

Tehseel *

Please select tehseel.

District (Auto-selected)

Region (Auto-selected)

Province (Auto-selected)

Country (Auto-selected)

City/Town *

Eligibility and Usage Information

5 Wheelchair Size Information *

Preferred Size *

Please select a wheelchair size.

Exact Size / Measurement Description (if any)

6 Previously used a wheelchair? *

Please select whether previously used a wheelchair.

Requires training for first-time use? *

Please select whether training is required.

Why need new wheelchair? *

Please specify why new wheelchair is needed.

Please provide description / reason why new wheelchair is needed *

Please specify other reason why new wheelchair is needed.

7 Wheelchair Users in Family *

Please select number of wheelchair users in the family.

Verification and Consent

Front CNIC Copy *

Click to upload

PNG, JPG or JPEG (max 5MB)

Front CNIC Copy is required.

Back CNIC Copy *

Click to upload

PNG, JPG or JPEG (max 5MB)

Back CNIC Copy is required.