1. Title:Dato’Dr.Mr.Ms.
Others:
2. Name:*
3. Nationality:*
4. NRIC/Passport:*
5. Gender:MaleFemale
6. Introducer:*
7. Mobile Phone No:*
8. Facebook:
9. Primary Email Address: *
10. Alternate Email Address:
11. Correspondence Address:*
12. Cancer Patient:YesNo
13. Volunteer:YesNo
(Willing to assist in activities)
I,*
hereby certify that the above information is true and agree to abide by the rules, regulations and ethical policies of Cansurvive Centre, should I be accorded membership.
Signature*
Date*
[Note: Cansurvive Centre Malaysia Berhad’s management committee reserves the right not to approve membership applications without providing any explanation]
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