Please provide us with details of the proposed community facility in need of a LifeStraw unit.

Your Name(*)
Please provide us with your full name.

Please provide us with your full name.

Your Email(*)
Please provide us with your email.

Please provide us with your email

Your Contact Number(*)
Please provide us with your telephone number

Please provide us with your telephone number in case we need to contact you

Your Organisation(*)
Please give us the name of the organisation/Rotary Club you represent.

Please give us the name of the organisation/Rotary Club you represent.

Proposed Facility(*)
Please enter the name of the facility.

Please give us the name of the community facility you propose.

Type of community facility you propose(*)

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Degree of water supply problem(*)

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Contact Information of Proposed Facility(*)
Please enter an address or telephone no of the proposed facility

Please enter contact information.

Additional Information(*)
Enter additional information.

Please give us some further information e.g. size of school / no of patients seen per day

Please fill in code(*)
Please fill in code
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