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Application No. issued by QASA Application Date Surname Initials ID Number Race Physical Address Disability Email Address TEL Are you Employed Your Income Make of Wheelchair A MAXIMUM OF 2 BATTERIES WILL BE SUPPLIED EVERY TWO YEARS TO A SUCCESSFUL APPLICANT EXCEPT IN THE CASE OF FACTORY FAULT BATTERIES. THIS PROJECT DOES NOT GUARANTEE A NEW SET OF BATTERIES TO EACH APPLICANT EVERY TWO YEARS. A COPY OF THIS DOCUMENT TO BE KEPT BY APPLICANT FOR FUTURE REFERENCE. FOR REGIONAL OFFICE USE ONLY...
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