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CCIL DATA REQUEST FORM
Requestor Information
Name of Organization / Institution
*
(Max length is 100)
Name and position of the person requesting data
*
(Max length is 100)
Address of Organization / Institution
*
(Max length is 100)
Phone / Mobile
(Max length is 15)
Email
*
(Max length is 25)
Name of the Authorized Signatory of the Organization / Institution
*
(Max length is 25)
Data Request Details
Date of Request
*
Data Request Description
*
(Max length is 100)
Period of Data
*
(Max length is 100)
Purpose of Data Request (Whether for Research, Commercial or Others)
*
Select an option
Research
Commercial
Others
If Research, provide a Description of Research, Research Objectives and Design (Kindly enclose a brief document)
*
(Max length is 200)
If Commercial / Others, please specify the Purpose
*
(Max length is 200)
Please provide any additional information about the request
(Max length is 1000)
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