JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
爱心防疫 送暖甲洞美门 Loving Caring for Beautiful Gate Kepong_ORDER FORM
Energy Depot 发起此义卖活动，与GOCARE携手合作为甲洞美门残障关怀中心筹款
Energy Depot and GoCare conducting the fundrasing campaign to raise fund for Beautiful Gate Foundation For The Disabled (Kepong)
Sign in to Google
to save your progress.
Learn more
* Indicates required question
NAME (ENGLISH)
*
Your answer
SHIPPING ADDRESS *
*
Your answer
HANDPHONE NUMBER *
Your answer
SHIPPING METHOD / PICKUP
*
Free Shipping (WEST MALAYSIA ONLY)
Self pick up @ GoCare Office( Wisma MCA KL
Self pick up @ Energy Depot Office (Selayang)
Other:
DONATION PACKAGE
*
Early Bird Package (RM50 ) : 3ply-medical mask (50 pcs) + 100pcs Alcohol Wipes (Limited 50 sets only!)
Package A (RM65 ) : 3ply-medical mask (50 pcs) + 100pcs Alcohol Wipes
Package B (RM100) : 3ply-medical mask x 2 boxes (100 pcs) + 200pcs Alcohol Wipes
Package C (RM200) : 3ply-medical mask x4 boxes (200 pcs) + 400pcs Alcohol Wipes
Package D: (RM500) : 3ply-medical mask x 12 boxes ( 600 pcs)+ + 500pcs Alcohol Wipes + 10pcs Face Shield
Package E: (RM1000) : 3ply-medical mask x 24 boxes ( 1200 pcs)+ + 1000pcs Alcohol Wipes + 15pcs Face Shield
Package F: (RM2000) : 3ply-medical mask x 50 boxes ( 2500 pcs)+ +2500pcs Alcohol Wipes + 20pcs Face Shield
Other:
Required
Donation ticket number (IF ANY, FOR GOCARE ONLINE PAYMENT ONLY, KINDLY CHECK YOUR EMAIL)
Your answer
Remarks
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
