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  • 义肢申请表格 FREE PROSTHESIS APPLICATION FORM

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    Shirley Tnay Moi Ping
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    请下载表格填妥后连同复印身份证，照片一张及医生证明书交到紫辉阁阁所。地址为：sublot 69-70, 3rd floor, Jalan Setia Raja, 93350 Kuching Sarawak. 电话：082-363732 Please download and complete the form and sent to the address below together with a copy of I.C, medical report and passport size photo. Address：sublot 69-70, 3rd floor, Jalan Setia Raja, 93350 Kuching Sarawak. Tel：082-363732

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    请下载表格填妥后连同复印身份证，照片一张及医生证明书交到紫辉阁阁所。地址为：sublot 69-70, 3rd floor, Jalan Setia Raja, 93350 Kuching Sarawak. 电话：082-363732 Please download and complete the form and sent to the address below together with a copy of I.C, medical report and passport size photo. Address：sublot 69-70, 3rd floor, Jalan Setia Raja, 93350 Kuching Sarawak. Tel：082-363732

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    95 views1 page

    义肢申请表格 FREE PROSTHESIS APPLICATION FORM

    Uploaded by

    Shirley Tnay Moi Ping
    请下载表格填妥后连同复印身份证，照片一张及医生证明书交到紫辉阁阁所。地址为：sublot 69-70, 3rd floor, Jalan Setia Raja, 93350 Kuching Sarawak. 电话：082-363732 Please download and complete the form and sent to the address below together with a copy of I.C, medical report and passport size photo. Address：sublot 69-70, 3rd floor, Jalan Setia Raja, 93350 Kuching Sarawak. Tel：082-363732

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Serial No/Siri No:

    Organiser/Penganjur : PERTUBUHAN MENINGGIKAN AKHLAK CHE HUI KHOR,KUCHING,SARAWAK.

    Technical Support & Advice / Unit Teknikal dan Penasihat:The Prosthesis Foundation Under The Patronage of The Princess Mother of Thailand
    /Date:04/09/2010 to 09/09/2010
    /Name/Nama: ()
    /Gender/Jantina:/Male/Lelaki( ) Female / Perempuan( )
    /Race/Bangsa: ( ) Melayu ( ) India ( ) lain-lain( )
    I/C NO/NO.K/P: /Age/Umur:
    Home Address/Alamat Rumah:
    Tel No:
    OCCUPATION/PEKERJAAN
    (i) /Pre-amputation/Sebelum Kudong: /Income/Pendapatan
    (ii)/Post-amputation/Selepas Kudong: /Income/Pendapatan
    /Office Address/Alamat Pejabat:
    Tel No:
    FAMILY BACKGROUND/LATAR BELAKANG KELUARGA
    (i)/Spouse's Name/Nama Pasangan
    (ii)/Occupation/Pekerjaan /Income/Pendapatan
    (iii)/No.of Children/Bilangan Anak /Income/Pendapatan
    (iv)/Parents/IbuBapa /Income/Pendapatan
    (v)// Residence/:Rent/Own/Lodging Rumah:Sewa/Sendiri/Tumbang
    /TYPE OF ARTIFICIAL LEG/JENIS MEMASANG KAKI:(X)
    A1:/Right Leg/Kaki Kanan( ) A2:/Left Leg/Kaki Kiri( ) A3:/Both Leg/Kedua-dua Kaki( )
    Note:All applications require prior examination of doctor.
    Nota:Permohonan mesti mendapat pemeriksaan dari sokongan doktor.
    B1:/Above Knee/Atas Lutut( ) B2:/Below Knee/Bawah Lutut( )
    Additional Application/Permohonan Tambahan:Yes/No
    (/For Occupation's Requirement/Untuk Keperluan Pekerjaan)
    /CAUSE OF AMPUTATION/AKIBAT KAKI DIPOTONG:
    /Inborn/Kelahiran( ) /Accident/Kemalangan( ) /Sickness/Penyakit:
    /Date of Amputation/Tarikh Kaki Dipotong:
    / Whether applied for free artificial legs before? / Sama ada pernah menggunakan kaki palsu?
    /Yes/Ada( ) /Where/Dimana? /Year/Tahun
    */Document Encl/Dokumen dilampirkan:
    1.Copy of IC / Salinan KP 2.Medical Report/Laporan Perubatan 3./Photo(1)/Gambar(satu)
    /Introducer:

    Applicant Signature/Tandatangan Pemohon Verfying Date/Tarikh Disemak: Approved by/Dilulus oleh:
    /Date/Tarikh

    FREE PROSTHESIS PROGRAMME / KEMPEN MEMASANG KAKI PALSU SECARA PERCUMA
    BORANG PERMOHONAN / / APPLICATION FORM
    Sublot 69-70, 3rd Floor, Stutong Parada,Jalan Setia Raja, 93350 Kuching,Sarawak,Malaysia.TEL:082-363732 FAX:082-369931
    Closing Date

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