Survey Form
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Email *
Company Name *
Company Registration Number (SSM) *
Manufacturing License Number (MITI/MIDA) or exempted
Business License Number (Local Authority) *
Address *
District *
Tel No. *
Fax No.
Official Email *
Products Manufactured
No of Workers (Total) *
No of Workers (Local) *
No of Workers (Foreign) *
Zone *
Name of Contact Person *
Position of Contact Person *
Contact No of Contact Person *
Email of Contact Person *
Are you interested to participant in this program if it is organized in Kedah (Tick your answer) *
Required
If yes - Prefer types of PPV
By submitting this form,
* I understand that this is a survey for future PIKAS implementation program in Kedah
* I agree and consent to organizer to contact me and process my details in relation to PIKAS.
* I understand that this is not a guarantee that the vaccine will be provided to my company
* I understand that there is a administration cost to be borne by our company to join this program
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