Covid-19 Vaccination Registration

Personal Information

Full Name *

Email Address *

Mobile Number *

Street Address *

Apartment, suite, etc

City

State *

ZIP / Postal Code

Country

1. Are you interested to take the COVID-19 vaccine? *YesNo

2. Are you interested to purchase the COVID-19 vaccine if available? *YesNo

3. Do you have any health complication or problem? *YesNo

4. Are you registered with the Department of Social Welfare Malaysia as a Disabled Person (OKU)? *YesNo

1. Is your company interested to take mass COVID-19 vaccination?YesNo

Number of persons

I hereby declare that the information provided is true and correct