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1 Applicant Role

Beneficiary Themself Guardian Breadwinner Family Member Relative / Companion Association Employee Health Entity Employee Charity / Partner Other (Specify)

2 Personal Information

First Name

Middle Name

Family Name

ID Type

National ID Iqama Visitor ID Border Number Birth Certificate / Birth Notification Passport

Nationality

Please specify nationality

ID Number

ID Expiry Date

Date of Birth

Age

Gender

Male Female

3 Contact Information

Mobile Number OTP verification code will be sent to this number

Alternative Contact Number

4 Social & Family Status

Marital Status

Single Married Divorced Widowed Separated Child / Minor

Number of Family Members

Number of Wives

Number of Sons

Number of Daughters

5 Address & Housing

Administrative Region

City of Residence

Brief Housing Description

National Address Code Saudi National Address short code (4 letters + 4 digits)

Housing Type

Apartment Villa Independent Floor Traditional House Independent Room With Family Employment Housing Charitable Housing Other (Specify)

Housing Ownership

Owned Rented Endowment Shared Provided by Charity Other (Specify)

Rent Amount (SAR)

6 Education & Employment

Education Level

Owns a Car

Yes No

Employment Status

Employed Unemployed

Able to Work

Yes No

7 Income Information

Income Level

Specify Income Level

Specify income source

Guardian or Breadwinner Name

Guardian or Breadwinner Mobile

8 Account Setup

Your mobile number will be your username for signing in.

Password

Confirm Password

Declaration & Consent *

I declare that all entered information is accurate, and I consent to the organization studying my data and verifying information and documents for the purpose of eligibility assessment and providing the appropriate service in accordance with available systems and capabilities.

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