Full Name :

Age :

Education :

Email :

Contact :

Province : --Select a province-- Province 1 Province 2 Bagmati Gandaki Province 5 Karnali Province 7

Districts : --Select a district--

Address :

Gender :
Male   Female   Others

Ethenicity Group : --Select an ethnic group-- Khash/Arya Dalit Janjati Madheshi Muslim Single woman LGBTIQ Disability Others

Please mention ethenicity :

Do you have voter id card?
  Yes     No

if yes, enter voter id number.

Enter Voter Id :

Facebook     Instagram     Twitter     Youtube    Tiktok    Other

Please mention social link

Did you get vaccinated?
  First    Both     No

If yes, carry the card with you.

Are you suffering from a cold, cuff, headaches, fever, now or within a week?
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Have you been affected by Coronavirus within a week?
  Yes     No

Have your family members been affected by Coronavirus within a week?
  Yes     No

Have you have seen any symptoms of Coronavirus now?
  Yes     No