Flood I.T. Form

Beneficiary Details:
Flood I.T. Form		back
		* fields are compulsory
Buyer Name *		*
Address *		*
City *		*
Pincode
Phone No. (O)
Phone No. (R)
Phone No. (Mobile or other) *		*
Caste
Occupation *		*
Monthly Income *		*
Student Name *		*
Birth Date *	_{eg. 2000-02-01 (year-month-day)}	*
School / College Name *		*
Studing in Std. / Class *		*
Address *		*
City *		*
Pincode
Phone No. *		*
* Whether opted for scholarship ?	Yes No	*
		*
Product Purchased:
Brand *	_{eg. HCL / HP / ACER}	*
Product *	_{eg. Laptop / Desktop}	*
Model *		*
Price *		*
Purchase Date *	_{eg. 2000-02-01 (year-month-day)}	*
Payment Option *	_{eg. CASH / By Loan}	*
Amount *		*
Lending Bank Name *		*
Address *		*
City *		*
Pin Code		*
	Submit