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National Centre of Disabled Persons (NCDP)
Information and Referral Services (IRS) Project
#3, Norodom
Blvd., Phnom Penh, Cambodia.
Tel:+855-23-210140, Fax:+855-23-213876
P.O Box: 140
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| 1. Full Name: |
Name in Khmer (Font: Limon S1):
Name in English:
*
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| 2. Application Date (Current
Date): |
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| 3. Current Address (Full
postal address): |
Provincial/Town/City:
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| 4. Birth Date: |
Age:
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5.
Contact:
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Contact Person:
Phone Number:
E-mail Address:
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6. Family or Permanent
Address:
(if different from Current Address) |
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| 7. Disability Categories: |
8. Sex:
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9. Languages
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Speaking
Reading
Writing
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10.
Education:
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Name and location of educational
From:
To:
Certificate
Major/Subject
institutions attended
or Degree |
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Name and location of vocational
From:
To:
Certificate Major/Subject
training institutions attended for
or Degree
SUBSTANTIAL training ( >1Year ) |
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Name and location of skills
From:
To:
Certificate Major/Subject
training institutions attended for
or Degree
MINOR training ( >1Year ) |
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| 11. Computer
Skill (Programs): |
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| 12. Rehabilitation Services
Information: |
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| 13. Service Known: |
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| 14. Marital Status: |
14b. Spouse (if Married):
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15. Children Living in house: |
School age children living in house:
Children in school:
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16. Disability family member: |
Do you have any disabled family members?
If yes who?
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17. Employment Status: |
19. Salary (If Employed) (US$): |
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18. Employment Histories (If Employed): |
Name and Address of the
From:
To:
Position
Reason
Companies or Gov/NGOs
or Occupation
of leaving |
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20. Main Duty of the Last Employed |
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21. Total Self Income (US$): |
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22. Skill Categories:
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or other:
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23. Discomfort in participation in community
activities: |
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24. Physical limitations in participating in
community activities: |
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| 25. Comment: |
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