Client Intake · World Relief Portal

WR Office

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Select	Name . sort ascending	Account Name . sort ascending	Address 1: City. sort descending	Address 1: State/Province. sort descending

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Legal First Name

Legal Middle Name

Legal Last Name

Preferred Name

Cell Phone

WhatsApp Number

Street Address

City

State

Zip

Birthday

Gender

Birth Country

Language Spoken at Home

Date of Entry into US

Primary Support Person/US Tie First Name

Primary Support Person/US Tie Last Name

Primary Support Person/US Tie Cell Phone

Please add the type of services needed. Be as descriptive as you can.

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