Registration form- Ujasiriamali Hub
Personal Data
Full Name
*
Gender
*
Male
Female
Other
I prefer not to disclose
Date of birth:
*
-
Mês
-
dia
Ano
Date
ID Number
*
ID Number
Education
*
Primary Education
Secondary
Tertiary
E-mail
*
Address Street
*
City
*
State/Province
*
Zip Code
*
Country
*
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Registration form- Ujasiriamali Hub
Business data
Do You Own A Business?
*
Yes
No
What is your business brand name?
*
Does your business have social media platforms?
*
Yes
No
Enter your business social media below:
*
How soon do you intend to start your own business?
*
Up to 30 days
Up to 60 days
Up to 90 days
I will not start my own business
Describe your business idea:
*
Would you be interested in a 100% free online coaching?
*
Yes
No
How did you find out about the course?
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Registration form- Ujasiriamali Hub
Socioeconomic Data
Are you currently studyng?
*
Yes
No
Do you wish to study or seek personal, professional or educational qualification?
*
Yes
No
Do you have health insurance?
*
Yes
No
Do you have recurring health problems?
*
Yes
No
Do you have special needs?
*
Yes
No
If yes, wich one?
*
How often do you consume alcohol or cigarettes?
*
Once a week
Thrice a week or more
Twice a week
I do not consume it
How often do you practice sports?
*
Once a week
Thrice a week or more
Twice a week
I do not practice sports
How many meals do you eat a day ?
1 meal a day
2 meals a day
3 meals a day
4 meals a day or more
How often do you eat meat?
*
Once a week
Thrice a week or more
Twice a week
I do not consume it
How often do you have access to culture? (cinema, theater, show, parties...)
*
Once a week
Thrice a week or more
Twice a week
I do not have acess to it
Do you wake up feeling motivated to perform your daily activities?
*
Never
Sometimes
Always
Rarely
Do you think that you are able to change your reality?
*
Never
Sometimes
Always
Rarely
Where do you buy your food?
*
Neighborhood grocery store
Supermarket
Do you consume tomato sauce or tomato puree?
*
tomato sauce
tomato puree
I do not consume it
Do you consume powdered juice or boxed juice?
*
powdered juice
boxed juice
I do not consume it
Do you have a bank account?
*
Yes
No
What is your current income?
*
Up to 447.000 TZS
447.000 TZS to 895.000 TZS
895.000 TZS to 1.342,000 TZS
More than 1.342,000 TZS
What is your main source of income?
*
Own business
Salary
Government assistance
Third parties
Freelance job
How many people are directly or indirectly depending on your monthly income?
*
1
2
3
4 or more
How much money is left after paying the bills?
*
Up to 44.717 TZS
44.717 TZS to 224.000 TZS
224.000 TZS to 447.000 TZS
More than 447.000 TZS
Submit
Should be Empty: