SERVE IN MERCY - Basic Groceries/Food Aid Form / Borang Barangan Runcit

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Nama / Name : *

IC No. / Passport : *

Warganegara / Nationality : *

Alamat Rumah / Home Address : *

BEC:

Nombor Telefon / Contact number : *

Pekerjaan / Job Profession : *

Bilangan tanggungan / Number of dependents : *

Saya memohon bantuan ini kerana / I'm applying for this aid because:- *

Kehilangan pekerjaan/sumber pendapatan sementara kerana MCO / Temporarily loss of income due to MCO

Kehilangan sumber pendapatan sepenuhnya / Permanently loss of job/income

Dikurantin / Quarantined

Lain-lain sebab / Others

Required

Lain - lain / Others :

Adakah anda menerima bantuan dari pihak lain dalam tempoh 3 bulan? / Have you been receiving any form of aid from any organization within the past 3 months? *

Ya / Yes

Tidak / No

Jika ya, senaraikan nama pihak NGO atau Kerajaan? / If yes, please state from which Government or NGO?

Borang diisi oleh / Form Completed by:

Sekiranya anda hanya mengisi borang bagi pihak pemohon, sila beri nama dan number telefon anda / If you're only filling the form on behalf of the receiver, please indicate your name and contact number.

Syarat - syarat kelayakan :

1. Warganegara Malaysia atau CDM Migrant Komuniti, yang bekerja tetapi telah kehilangan sumber pendapatan atau tidak di bayar gaji sepanjang tempoh dikenakan Perintah Pengawasan dan Pemerhatian bagi kontak Covid-19.

2. Warganegara Malaysia atau CDM Migrant Komuniti, yang bekerja tetapi telah kehilangan sumber pendapatan atau tidak di bayar gaji sepanjang tempoh menjalani rawatan di wad hospital ekoran Covid-19.

3. Bantuan keperluan barangan runcit adalah terhad kepada kawasan liputan CDM. Bagi permohonan dari luar kawasan liputan CDM akan dirujuk kepada gereja kawasan terdekat.

Eligibility requirements :

1. A Malaysian citizen or CDM Migrant Community, who works but has lost his source of income or has not been paid his salary during the period is subject to the Surveillance and Observation Order for Covid-19 contacts.

2. Malaysian citizens or CDM Migrant Community, who works but have lost their source of income or have not been paid during the period undergoing treatment in a hospital ward due to Covid-19.

3. Supply of aid by CDM is within CDM Church boundary. Those living outside the boundary, the application will be forwarded to respective church organization.

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