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New Zakat Network Application
I Acknowledge and Consent:
By filling out or having the formed filled on my behalf and submitting this zakat application, I authorize the organization to verify the information contained therein. I understand I may be required to present proof of all the statements in this application upon request. I understand a representative of the organization will verify the necessary information in order to render any assistance to me in a timely and discreet manner. I am aware due to unforeseen circumstances, assistance I requested may be unavailable. When I submit this zakat application for review, I certify I have read, or had read to me all the statements in this online form and all the information given is true, correct, and complete to the best of my knowledge. If this application is approved, I authorize the zakat reviewers to pay any owed vendors directly on my behalf.
Please specifiy the organization that you would like to submit this Zakat Network application to (* required):
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Islamic Community Center of Laurel
Maryland Institute of Development
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Applicant Information
4% Complete
Email:
*
SSN:
*
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-
First Name:
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Middle Name:
*
Last Name:
*
Date of Birth:
*
Phone #:
*
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-
Gender:
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Marital Status:
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(Select One)
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Nationality:
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Afghan
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Antiguans
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Dutch
East Timorese
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German
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Greek
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Citizenship:
*
(Select One)
Permanent Resident
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Masjid Name:
*
Masjid Ph #:
*
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Skills, Certs and Education
Languages:
Abkhaz
Afar
Afrikaans
Akan
Albanian
Amharic
Arabic
Aragonese
Armenian
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Latin
Latvian
Limburgish
Lingala
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Luba-Katanga
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MÄori
Macedonian
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Malay
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Norwegian
Norwegian Nynorsk
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Sign Language
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Urdu
Uzbek
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Vietnamese
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Western Frisian
Wolof
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Zhuang
Languages Spoken:
*
Enter a Skill or Certification then Add to your List:
Skills and Certifications:
Highest Education Completed:
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Lower Than High School Diploma
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Associate Degree or Certificate
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International School /
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School Name:
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School City:
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School Zip:
*
Assets and Support
91% Complete
Cash Value:
$
Gold Value:
$
Silver Value:
$
Investments:
$
Retirement:
$
Are you receiving any temporary assistance?
Assistance:
$
Yes
No
Do you have Insurance / Medicare / Medicaid?
*
Life Insurance:
$
Debt Value:
$
Child Support:
$
Ch. Sup. Freq.:
(Select One)
Daily
Weekly
Bi-Monthly
Monthly
Yearly
Food Stamps:
$
F.S. Frequency:
(Select One)
Daily
Weekly
Bi-Monthly
Monthly
Yearly
Who Assisted:
Employment (or Previous)
11% Complete
I am not nor have been previously employed
Employer:
*
Start Date:
*
End Date:
Position:
*
Phone #:
*
-
-
Monthly Salary:
*
$
Street:
*
City:
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State:
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Maryland
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Other
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Zip Code:
*
Dependent Information
0% Complete
I do not have any dependents
First Name:
*
Middle Name:
*
Last Name:
*
Your Current List of Dependents Are Shown Below:
Date of Birth:
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Gender:
*
Male
Female
Relation:
*
(Select One)
Father
Mother
Son
Daughter
Husband
Wife
Brother
Sister
Grandfather
Grandmother
Great Grandfather
Great Grandmother
Grandson
Granddaughter
Grandson
Uncle
Aunt
Nephew
Niece
Cousin
Other
References
0
(2 Required)
0% Complete
First Name:
*
Middle Name:
*
Last Name:
*
Relationship:
*
(Select One)
Family
Friend
Coworker
Fellow Student
Other
Phone #:
*
-
-
Your Current List of References Are Shown Below:
Known Since:
*
Street:
*
City:
*
State:
*
(Select One)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
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Nevada
New Hampshire
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New Mexico
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North Carolina
North Dakota
Ohio
Oklahoma
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Other
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
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Zip Code:
*
Artifacts
0
(Gov't ID Req'd)
0% Complete
Artifact Type:
*
Government Photo Identification
Student Loan
Lease/Mortgage Bill
Utility Bill
Medical Bill
Tuition Bill
Eviction Notice
Local Masjid Reference Letter
Other
Your Current List of Artifacts For This Application Are Shown Below:
Personal Statement
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Briefly describe your personal and/or family needs (1000 characters max):
*