Tell us more

Tell us more

We welcome all enquiries pertaining to a request for donation of a WaterSource alkaline water ionizer. Complete the form and submit. You will receive a call from us shortly!

People in need

Be a Sponser

Personal Particular

Purpose(please state clearly why do you need the ionizer for)

Demographic

Marital Status :

Single

Married

Divorced

Others (please specify:)

Employment Status :

Employee

Self-Employed

Unemployed

Homemaker

Retired

Student

Others (please specify:)

Household Income :

Under $12,000

$13,000 to $24,000

$25,000 to $36,000

$37,000 to $48,000

$49,000 to $60,000

Above $60,000

Others (please specify:)

Type of House :

2-Room

3-Room

4-Room

5-Room

Others (please specify:)
 

Health condition of family members:


Medical report attached

I am willing to submit progress report for the purpose of study

I am declare that above information is true

Donor

Individual

Corporate

Sponsor Category