CUALA

Company Name

Are we okay to email you?

How can we reach you on mobile?

SMS opt-in / preference

1st line of your address

2nd line of your address

3rd line of your address

Post code

Country

City - type to search

Additional questions

1. What city are you based?

2. What country are you based?

3. What is your current employment status?

4. What is your marital status?

5. Do you have dependants in your care? Choose the most applicable option

6. Type of Request

7. Please describe the support you need from us. What is your current situation and what do you need? Please add as much detail as possible.

8. Have you reached out to your class for support? If yes, what support did you get?

Re-confirmation - Matric. Number

Please enter your Matric. Number. This must match what we have on our records.

Note - after hitting the Submit button, if you see a blank page, you may need to scroll up on your device as the confirmation will be at the top of the page!

Please wait!

Welfare application form

Company Name

Are we okay to email you?

How can we reach you on mobile?

SMS opt-in / preference

1st line of your address

2nd line of your address

3rd line of your address

Post code

Country

City - type to search

Additional questions

1. What city are you based?

Please use the space below to provide your answers.

2. What country are you based?

Please select one of the options using the drop down list.

3. What is your current employment status?

Please select one of the options using the drop down list.

4. What is your marital status?

Please select one of the options using the drop down list.

5. Do you have dependants in your care? Choose the most applicable option

Please select one of the options using the drop down list.

6. Type of Request

Please select one of the options using the drop down list.

7. Please describe the support you need from us. What is your current situation and what do you need? Please add as much detail as possible.

Please use the space below to provide your answers.

8. Have you reached out to your class for support? If yes, what support did you get?

Please use the space below to provide your answers.

Company name

Company number

Vat number

Job role/title

Type of business

Business activities

Business email

Business telephone

Business mobile

Business address

Business Website (or a link to your business social media page)

Bank name

Bank account sortcode

Bank account number

Re-confirmation - Matric. Number

Please enter your Matric. Number. This must match what we have on our records.