Capture Applications Details Form

Farm Name *
Salutation
First Name
Last Name *
ID_Number *
Gender
Date of Birth *	(yyyy-mm-dd)
CellPhone Number
Home Phone
Email Address
Street Address
City
Province
Postal Code

Is the Applicant an ODI
Relationship to ODI
Number Of Beneficiaries
Name of Originally Dispossessed Individual
Documents Submitted
Referred By
ID Copies ODI *
Death Certificate of ODI
Application form *
Affidavit Attached *
Power of Attorney signed? *