Selection form for institutions wishing to receive support institution name Date of incorporation, creation and/or registration Location (head office) type of institution Full name and function of the person submitting the form on behalf of the organisation/institution Representative address Tel Email address Fax website (optional) Briefly summarise the objectives and mission of your institution Briefly detail the internal structure of your institution Number of members in your institution Types of members of your institution Types of members of your institution People Institution(s) Other (please specify) Other (s), please indicate Number of people cared for by the institution Category of persons covered (age range) gender gender Male Female male and female Number (for each gender) Characteristics of the pensioners on admission to the institution (disabled, orphan, etc.) Indicate the geographical scope of your institution Indicate the geographical scope of your institution international regional / sub-regional national Please specify your most significant geographical representation Please specify your most significant geographical representation Africa Europe et America Asia and Pacific Briefly summarise the activities of your institution List the main needs of the institution How did you hear about HAMA FOUNDATION? How did you hear about HAMA FOUNDATION? social networks website relatives word of mouth posters others Other, please specify Did you encounter any problems when filling out the form? Did you encounter any problems when filling out the form? Yes no If yes, give details Other information that you consider important Submit Do you have any questions about the form? Contact us .