Request for Dispatching Domiciliary Care Worker

Filing No.

Name

(in Korean)

Gender

Male/Female

(in Chinese)

Date of birth

Details of designation as an aged beneficiary for national basic living security

Tel No.

Address

Daily-life conditions

Walking

○ Can walk ○ Little difficult to work ○ Can walk only with an assistive device ○ Can move by wheelchair ○ Unable to move

Degree of mobility

○ Unable to do chores on my own ○ Unable to do cooking, laundering

○ Can go outside to buy goods

Other information for reference

Describe inconveniences in detail

Information about family

Requested date and time of dispatch

Details of service requested

○ Compassionate visit ○ Counselling ○ Greeting by phone ○ Information about welfare facilities for the aged

○ Cleaning ○ Laundering ○ Cooking ○ Errands

○ Shopping ○ Others ( )

※ Please draw a map showing the way to your house on the back in detail.

I hereby request you to dispatch a domiciliary care worker.

Date:

Applicant: (signature or seal)

Attached documents: One set of documents certifying that the applicant is a beneficiary under the National Basic Living Security Act (if the applicant is a beneficiary)

To: The Head of Seoul ○○ General Welfare Center

210㎜×297㎜ (permanent paper (class 1) 60g/㎡