Breast Cancer Patient Fund Application Form

Personal Details
Martial Status*
Employment Status*
Occupation / Job Description
Employer's / Business Name
Employer's / Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Monthly Income / Pension (RM)*
*Please attach a copy of your latest payslip and bank statements (current). If self-employed, please get verification from the head of village/head of community/commissioner of oath.
If unemployed or retired without pension, what is your source of income / financial aid to support you?*
Estimated Average Monthly Income for Self-Employed / Business Owner
*Please attach a copy of your latest payslip and bank statements (current). If self-employed, please get verification from the head of village/head of community/commissioner of oath.
Have you received any other financial aid / medical assistance for your treatments?
What is the source of financial aid/medical assistance for your treatments received?
Please specify which foundation / NGO
The amount received (if any)

Spouse and Children Details
Spouse's Full Name*
*Full name as per NRIC/Passport
Spouse's IC Number *
*Identification Card number (IC)
Spouse's Employment Status*
Spouse's Occupation*
Spouse's Employer / Business Name
Spouse's Employer / Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's Estimated Average Monthly Income for Self-employed / Business Owner*
*Please attach a copy of your latest payslip and bank statements (current). If self-employed, please get verification from the head of village/head of community/commissioner of oath.
Spouse's Monthly Income / Pension (RM)*
*Please attach a copy of your latest payslip and bank statements (current). If self-employed, please get verification from the head of village/head of community/commissioner of oath.
If unemployed or retired without pension, what is your source of income / financial aid to support you?*
Average income / financial aid received *
How many children are still in school /college /university /OKU?*
How many boys
Age of boy #1
Age of boy #2
Age of boy #3
Age of boy #4
Age of boy #5
Age of boy #6
Age of boy #7
Age of boy #8
Age of boy #9
Age of boy #10
How many girls
Age of girl #1
Age of girl #2
Age of girl #3
Age of girl #4
Age of girl #5
Age of girl #6
Age of girl #7
Age of girl #8
Age of girl #9
Age of girl #10
How many children are working?
Do you have any other dependents?
How many dependents?
Who are your dependents?
Please state who is your dependent relative

Lifestyle Habits and Physical Activity
How would you describe your overall diet?
Are you currently smoking or vaping?
Are you currently consuming alcohol?
Did you engage in any form physical exercise or activities?
How often do you engage in physical exercise or activities?
What types of exercise or physical activities do you enjoy or participate in regularly?
Engagement and Future Participation
How did you know about Breast Cancer Foundation?
Have you attended any of Breast Cancer Foundation's program and activities?
Would you be interested to join our program and activities in the future?
How much are you willing to spend on entrance fee if you decide to join in the future?
Which activity have you attended before?

Attachments
Copy of Applicant’s Identification Card.*

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Copy of Applicant’s Spouse Identification Card.*

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Copy of Applicant’s Children's IC or Birth Certificate (below 17 years old /college /university), Dependents IC, OKU Card.

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Latest Recommendation / Support Letter from the Surgeon / Current Doctor / Oncologist / Medical Officer.*

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Copy of 3 months latest bank statement.*

*Please make sure the bank statements are clear.
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Copy of Latest Pay slip or Self-employment verification letter.

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If the spouse is unemployed due to illness, please attach the medical report.

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Acknowledgment
Applicant's Bank Name*
Applicant's Bank Account Number*
* Please do not include the dash ( - ). Please make sure the account name is under the applicant's name.
I hereby confirm that the information given above is correct and true. I also hereby agree that all information given can be used by Breast Cancer Foundation for marketing purposes only.
Signature*

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Applicant Name*
Application Date

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*Pick today's date
Who is filling out this BCF Patient Fund form?*
Name of person who filling out the form*
Email of the person who is filling out the form*
fatimah@example.com
Phone Number of person who is filling out the form*
Please enter a valid phone number.
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Personal Details