Contribution Form For Individuals

Assessment of Diaspora Contribution Form For Individuals
To be completed by the head of household, one per household.

*(denotes required field)

First Name: *

Middle Name:

Last Name: *

Profession:

Are you a business owner?

If yes please describe.

What is the number if registered voters in your household?

Are you part of any groups or organizations?

What is your hometown in Haiti?

How many family members do you have Haiti?

How much money did you contribute to charities helping Haiti each year?

Email Address:

Phone Number:

What services would you like Konbit to offer?

What resources can you bring to Konbit?

CAPTCHA Code: *

Important Links

Konbit News Feed
- Our partner Color of Hope's recap of our trip to Haiti distributing lights http://t.co/qmk9EOMd about 1 week ago from HootSuite
- Distributing solar lights to Haiti 4/27/12 http://t.co/3I0pnLza about 1 week ago from HootSuite
- Konbit for Haiti & Color of Hope will be in Haiti this month to give solar lamps to children so they can study at night http://t.co/jfORGWVq about 3 weeks ago from HootSuite
- Konbit for Haiti & Color of Hope will be in Haiti this month to give solar lamps to children so they can study at night http://t.co/f3GVur9W about 3 weeks ago from HootSuite
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