Please enable JavaScript in your browser to complete this form.Name *FirstLastNom / PrénomEmail *Adresse emailPhone *Numéro de téléphoneAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAdresseDate of Birth *Date de naissanceWhich Jamaat are you a member of? *BIRMINGHAMCOUNCIL OF SWITZERLANDESSEXGLOUCESTERHUJJAT LONDONHYDERI LONDONLA CHAUX DE FONDS SWITZERLANDLEEDSLEICESTERMARSTA SWEDENMILTON KEYNESPARIS NORTHPARIS SOUTHPETERBOROUGHTROLHATTAN SWEDENWATFORDWESSEXDe quel Jamaat êtes-vous? How much money would you like to claim from the Imam Reza Hardship Fund? *£100£200£300£400£500Quel montant souhaitez vous recevoir ?Bank Details ( Sort Code)Bank Details (Account Number) IBAN (for bank accounts outside UK)Votre IBANBIC/ Swift (for accounts outside UK)Votre BIC / SwiftWhat type of accommodation do you live in? *OwnedPrivately rentedSocial housingEtes-vous : Propriétaire / Locataire / Logement social What is your employment status? *EmployedSelf-employedUnemployedRetiredHousewifeVotre catégorie professionnelle : Employé / A votre compte / Sans emploi / Retraité / Femme au foyerHow many dependants reside in your housing? *None12345more than 5Combien de personnes dans votre foyer ?Do you or any member of your household declared disabled? *YesNoQuelqu'un dans votre foyer est-il à mobilité réduite ?I hereby declare as Allah (SWT) is my witness that I am a genuine applicant and all the information provided is true to the best of my knowledge. *Declaration of Truth (please tick)Je déclare sur l'honneur la véracité des informations ci-dessous (cocher la case)I hereby consent to The Council of European Jamaats to collect, use and store my personal data as required in accordance with the charity’s constitution and the Data Protection laws (including but not limited to the Data Protection Act 2018 and GDPR 2018) afforded by the governing laws of England and Wales. *GDPR Decleration (please tick)Le Coej peut utiliser et sauvegarder mes données personnelles selon les lois Date Protection Act 2018 et GDPR 2018 (cocher la case)Submit
