Lhak Sam Beneficiary Support Request Form

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1. Full Name *

2. Gender *

3. Date of Birth *

4. Age *

5. CID Number *

6. Occupation *

7. Marital Status *

8. Educational Qualification *

9. Contact Number *

10. Email Address *

11. Present Address(Village, Gewog, Dzongkhag) *

12. Permanent Address(Village, Gewog, Dzongkhag) *