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Application Template Review

2 by Matthew Kaufman
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City of Los Santos
Medical Health and Rights Assistance for the Disabled Application
  • PERSONAL INFORMATION
    • Forename & Surname: Answer Here
      Date of Birth: Answer Here
      Residence Address: Answer Here
      Phone Number: Answer Here
      E-mail address: Answer Here

      Select your citizenship status:
      • U.S. Citizen
        Non-U.S. Citizen
    • Select your gender:
      • Male
        Female
        Other
  • TYPE OF DISABILITY
  • Date of Diagnosis: Answer Here
  • Medical Documentation Attached: Yes | No
  • Documentation:
  • Physician's Name & Contact Information: Answer Here
  • ASSISTANCE REQUESTED
  • Medical Consultation
  • Financial Assistance for Treatment
  • Mobility Aids or Assistive Devices
  • Home Care Support
  • Legal Rights Assistance
  • Other (Please Specify):
  • INCOME INFORMATION
  • Do you have any income?:
  • If yes, how much do you receive per month?: Answer Here
  • What is the source of your income?: Answer Here
  • SUPPORTING DOCUMENTS
  • Medical Reports
  • Disability Certificate
  • Financial Proof (if applicable)
  • Other Documents
  • ADDITIONAL INFORMATION
  • Do you have any disabilities or medical conditions?: Yes / No
  • If yes, please explain: Answer Here
  • Do you receive any other benefits?: Yes / No
  • If yes, please specify: Answer Here


Declaration:
I, [Your Name], hereby declare that all the information provided in this application is true and accurate to the best of my knowledge. I understand that any false information may result in disqualification from receiving assistance.


Signature:
Date:
  • (( OUT OF CHARACTER ))
  • Country of Residence & Timezone: Answer Here

    Discord ID: Answer Here

    Please list all your characters and their levels:
    • Name Surname
    • Name Surname
    • ...

Template

3 by Matthew Kaufman
  • Application Subject

    Code: Select all

    #DSS-01-25 - Medical health and rights assistance for the disabled | Firstname Lastname
    Application Form

    Code: Select all

    [divbox=white][center][img]https://i.imgur.com/b9f9JTN.png[/img][/center]‎
[center][size=110]City of Los Santos[/size]
[size=130][color=#000000][b]Medical Health and Rights Assistance for the Disabled Application[/b][/color][/center][/size]
[list=none][divbox=black][center][color=#FFFFFF][b]PERSONAL INFORMATION[/b][/color][/center][/divbox][/list]
[list=none][list=none]


[b]Forename & Surname:[/b] [i]Answer Here[/i]
[b]Date of Birth:[/b] [i]Answer Here[/i]
[b]Residence Address:[/b] [i]Answer Here[/i]
[b]Phone Number:[/b] [i]Answer Here[/i]
[b]E-mail address:[/b] [i]Answer Here[/i]

[b]Select your citizenship status:[/b]
[list=none]

[cb][/cb] U.S. Citizen
[cb][/cb] Non-U.S. Citizen
[/list][/list]
[list=none]
[b]Select your gender:[/b]
[list=none]
[cb][/cb] Male
[cb][/cb] Female
[cb][/cb] Other
[/list][/list][/list]
[list=none][divbox=black][center][color=#FFFFFF][b]TYPE OF DISABILITY[/b][/color][/center][/divbox][/list]
[list=none]
[*] [b]Date of Diagnosis:[/b] [i]Answer Here[/i]
[*] [b]Medical Documentation Attached:[/b] Yes [cb][/cb] | No [cb][/cb]
[*] [b]Documentation:[/b]
[*] [b]Physician's Name & Contact Information:[/b] [i]Answer Here[/i]
[/list]
[list=none][divbox=black][center][color=#FFFFFF][b]ASSISTANCE REQUESTED[/b][/color][/center][/divbox][/list]
[list=none]
[*] [cb][/cb] Medical Consultation
[*] [cb][/cb] Financial Assistance for Treatment
[*] [cb][/cb] Mobility Aids or Assistive Devices
[*] [cb][/cb] Home Care Support
[*] [cb][/cb] Legal Rights Assistance
[*] [cb][/cb] Other (Please Specify):
[/list]
[list=none][divbox=black][center][color=#FFFFFF][b]INCOME INFORMATION[/b][/color][/center][/divbox][/list]
[list=none]
[*] [b]Do you have any income?: [/b][cb][/cb] 
[*][b] If yes, how much do you receive per month?:[/b] [i]Answer Here[/i]
[*] [b]What is the source of your income?:[/b] [i]Answer Here[/i]
[/list]
[list=none][divbox=black][center][color=#FFFFFF][b]SUPPORTING DOCUMENTS[/b][/color][/center][/divbox][/list]
[list=none]
[*] [cb][/cb] Medical Reports
[*] [cb][/cb] Disability Certificate
[*] [cb][/cb] Financial Proof (if applicable)
[*] [cb][/cb] Other Documents
[/list]
[list=none][divbox=black][center][color=#FFFFFF][b]ADDITIONAL INFORMATION[/b][/color][/center][/divbox][/list]
[list=none]
[*] [b]Do you have any disabilities or medical conditions?:[/b] Yes [cb][/cb] / No [cb][/cb]
[*] [b]If yes, please explain:[/b] [i]Answer Here[/i]
[*] [b]Do you receive any other benefits?:[/b] Yes [cb][/cb] / No [cb][/cb]
[*] [b]If yes, please specify:[/b] [i]Answer Here[/i]
[/list]
[hr][/hr]
[br][/br]
[b]Declaration:[/b]
I, [b][Your Name][/b], hereby declare that all the information provided in this application is true and accurate to the best of my knowledge. I understand that any false information may result in disqualification from receiving assistance.
[br][/br]
[b]Signature:[/b]
[b]Date:[/b]
[list=none][divbox=black][center][color=#FFFFFF][b](( OUT OF CHARACTER ))[/b][/color][/center][/divbox][/list]
[list=none]
[b]Country of Residence & Timezone[/b]: [i]Answer Here[/i]

[b]Discord ID[/b]: [i]Answer Here[/i]

[b]Please list all your characters and their levels[/b]:
[list=none]
[*] Name Surname
[*] Name Surname
[*] ...
[/list]

[/list]
[/divbox]
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