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( Please give details of the person availing the service within India )
Name* A value is required.
Surname* A value is required.
Date Of Birth (dd-mm-yy) Invalid format.
Gender
Marital status
If married  
Spouse' date of birth (dd-mm-yy) Invalid format.
Wedding anniversary (dd-mm-yy) Invalid format.
Home phone (Please include STD code) * A value is required.Invalid format.
Mobile phone (Please include ISD and STD code) * A value is required.Invalid format.
E-mail Invalid format.
Detailed address where the service is to be provided (min 75 characters) *   A value is required.Minimum number of characters not met.
Nearest landmark
City
Pincode
Alternate contact within India  (To be contacted in times of emergency or if recipient is not reachable on phone)
Name
Phone (Please include ISD and STD code)
Details of person requesting the service
Name* A value is required.
Surname* A value is required.
Gender
Designation
Relation with family member availing the service in India
E-mail* A value is required.Invalid format.
Phone (Please include ISD and STD code) * A value is required.Invalid format.
Current location of the person requesting the service
Special instructions to Maya CARE during their interactions with the senior citizen

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