Wheelchair Application — PKRM

1 Personal Information

Full Name (as per IC) *

IC Number *

Format: YYMMDD-PP-XXXX. Date of birth and gender will be auto-detected.

Date of Birth

Gender

Race *

Religion *

Phone Number *

Email (optional)

Address Line 1 *

Address Line 2

Postcode *

City & state will auto-fill

City *

District *

State *

Disability Type *

Description of Condition *

Minimum 50 characters

Are you registered as OKU with JKM? *

Yes No

Attending Doctor / Medical Officer

Doctor's Name *

Doctor's Phone

Hospital / Clinic *

This information is kept strictly confidential and used only to determine eligibility.

Monthly Household Income (RM) *

Household Size *

Employment Status *

Are you a BSH/STR recipient?

Ya / Yes Tidak / No

Type of Wheelchair Needed *

Do you have a caregiver? *

Ya / Yes Tidak / No

Have you received a wheelchair from PKRM before? *

Ya / Yes Tidak / No

Reason for Application *

Minimum 100 characters. Be as detailed as possible.

0 chars