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SCAN Membership (Lifetime)
25 June 2021
RM
110.00
Title
(Required)
Mr
Mdm
Ms
Dr
Other
Name (as per IC)
(Required)
or passport
I.C. / Passport No
(Required)
Date of Birth
(Required)
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Gender
(Required)
Male
Female
Marital Status
Home Address
(Required)
Street Address
Address Line 2
City
State
Postcode
Mailing Address is the same as above
Mailing Address is the same as above
Mailing Address
(Required)
Street Address
Address Line 2
City
State
Postcode
Home Tel No
Mobile Tel No
Office Tel No
Email
(Required)
Enter Email
Confirm Email
Consent
(Required)
I agree to the statement below
I hereby apply for Membership of the Pertubuhan Untuk Advokasi Dan Kesedaran Kanser Kuching and declare that I hereby agree to abide by the Constitution and Bye-Laws of SCAN
Date
(Required)
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DD
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YYYY
YYYY
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1931
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1921
1920
Additional Information
Information in this section is not required for membership but will help us understand you the member more.
I am a
Cancer Patient / Survivor
Caregiver of a cancer patient
tick all that applies
Cancer Patient / Survivor Information
What Cancer were you diagnosed with?
What Stage was your cancer? (at diagnosis)
You can enter I don't remember or I don't know.
In what year were you diagnosed with cancer?
Are you currently under treatment?
Yes
No
Are you in remission?
Yes
No
Caregiver Information
What Cancer was the person you are caring for diagnosed with?
What Stage was their cancer? (at diagnosis)
You can enter I don't remember or I don't know.
In what year were they diagnosed with cancer?
Are they currently under treatment?
Yes
No
Other
Are they in remission?
Yes
No
Other
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SCAN Membership (New Annual)
RM
30.00
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