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Peniaga dan Usahawan Kulai
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Nama
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Your answer
Warganegara
*
Warganegara Malaysia
Bukan Warganegara
No. Kad Pengenalan / Passport
*
Your answer
No. Telefon
*
Your answer
Alamat
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Your answer
Umur
*
Your answer
Jantina
*
Lelaki
Perempuan
Penyakit Kronik
*
TIADA
Kencing Manis
Darah Tinggi
Penyakit Jantung
Kolesterol Tinggi
Asma
Kanser
Penyakit Paru-paru Kronik
Stroke/Angin Ahmar
Imuniti Rendah
Obesity
Other:
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Adakah Anda Telah Menerima Vaksin Covid-19?
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Ya
Tidak
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