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INTAKE FORM

(I.D. photo)

Name: _____________________________________________________
Date of Birth: _________________________________________________
Nationality: _________________________________________________
Profession: _________________________________________________

Congregation/organization: ______________________________________
_______________________________________________________________

Mailing address: _____________________________________________
_______________________________________________________________
_______________________________________________________________

Visiting address: _____________________________________________
___________________________________________________________

Country: ____________________________________________________

(only if applicable)

Telephone no.: _______________________________________________
Fax no.: ____________________________________________________
E-mail: _____________________________________________________

References: _________________________________________________
___________________________________________________________

In contact with Stichting Liliane Fonds through:

Benjo Lee
Streams in the Desert

General comments: (briefly describe your involvement with children and youngsters with a disability)

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________


I, _________________________, have read the policy of Stichting Liliane Fonds and promise to follow the guidelines and use the funds entrusted to me only for individual assistace to children and youngsters with a disability.

Signature: ____________________________
Date: ____________________________


Please fill in this form and send back to:

Stichting Liliane Fonds
Havensingel 26
5211 TX s'-Hertogenbosch
Netherlands

E-mail: fwillockx@lilianefonds.nl
___________________________________________________________________

NOTE: (delete this section when submitting to SLF)

Send an e-mail copy of this form to SitD (Benjo_Lee@juno.com), no pic necessary. After evaluation, print this out and fill up with your photograph and send to the SLF address via post office.

Signatory mediator must be responsible in communications with SLF and SitD, especially by e-mail.