BW Generation 10Anniversay Give Back Plans

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Application Form

Email *

BW Generation Give Back to CARE GIVERS

I agree for BW Generation to send responses to this application and any helpful communications, including information on BW Generation products and services. *

BW Generation is compliant with the Privacy and Data Protection Act. Please be assured that your details will not be used for any other purpose. Your Email and Mobile Number is required in order to arrange and confirm the delivery of your Free Sample(s)

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Required

I would like to apply for the following BW Generation Give Back Plans. (*note you may change your plan going forward) *

APPRECIATION : Monthly Gift Voucher $40 : Min Spend $160 per order : Max 10mths x $40 = $400

CARE : Monthly Gift Voucher $50 : Min Spend $200 per order: Max 10mths x $50 = $500

DIGNITY : Monthly Gift Voucher $60 : Min Spend $240 per order : Max 10mths x $60 = $600

Family Name *

Given Names *

Gender

Male

Female

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Mailing Address *

Postal Code *

Singapore Mobile Phone Only (Please do not use your LandLine number because, we will Whats App you to process your application) *

I/We have a : *

Letter from AIC approving our Subsidies

Other:

Required

This Application on behalf of *

Myself as the CareGiver

For my Loved One that I am caring for (Please provide details below)

Other:

If you are making application on behalf of BLUE CHAS card and/or approved AIC SMF recipient please provide details *

My Father

My Mother

My Spouse

Other:

Which caregiving supplies other than Adult Diapers and Incontinence Products do you purchase regularly? *

Wet Wipes

Hand Sanitizer

Gloves

Masks

Glucerna

Ensure

Barrier Cream

Feeding Tubes, PH Indicators

Wounds and Sores management products

Other:

Required

Which brand of Adult Diapers do you currently purchase? *

Which shop(s) do you currently buy your Care Giver Supplies from? *

How did you hear about BW Generation? *

This is the last question. Thank you for your Request for Sample

I am already a customer of BW Generation

Friend's / Family's Recommendation

From Google Search

Referred by Hospital/Medical Staff

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Seen your products in Lazada

Seen your products in Qoo10

Seen your products in Shopee

Seen your products in other Online sites

Other:

TERMS & CONDITIONS *

i AGREE

Required

A copy of your responses will be emailed to the address you provided.

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