NC CONGOLESE POPULATION COUNT

NC Congolese Population Count.

Please, fill out this form if you are of Congolese Origin, 18+, and live in North Carolina. Only the numeric count and cities may be disclosed to 3rd party community partners for service purpose. The names, addresses, Date of birth and phone numbers collected on this form are for organizational purposes only and will not be disclosed to any 3rd party without prior consent of person filling out this form.
Recensement de la population Congolaise de NC

Priere de remplir ce formulaire si vous etes d'origine Congolaise, age de 18+ et vivez dans le North Carolina. Seuls le denombrement numerique et les villes seront divulgues aux partenaires pour des fins de service. Les noms, adresses, dates de naissance et numeros de telephone recueillis sur ce formulaire sont exclusivement pour des fins organisationnelles et ne seront pas divulgues a des tiers sans le consentement de la personne remplissant ce formulaire.
Name/Nom*

First NameMiddle NameLast Name
Spouse / Epoux(se)

First NameMiddle NameLast Name
Your Age / Votre age *
Gender/Genre*
How many children or dependents under 18 do you have? Vous avez combien d'enfants de moins de 18 ans?
You Speak? Vous parlez?*

LingalaSwahiliKikongoTshilubaFrenchEnglish
Location*

Street Address

Street Address Line 2

City

Zip Code
Primary Contact Number

Area CodePhone Number
I, First Name Last Name , was authorized by the person named above to fill out this form on his/her behalf.
Signature
Should be Empty:

NC Congolese Population Count.