Commit to Quit – Quit Now Campaign – Action on Smoking and Health (ASH) MMA

Nama/Name *

Sila isikan nama seperiti dalam kad pengenalan. Please fill in your name as in the identity card.

Tarikh Lahir/Date of Birth *//

No Kad Pengenalan/Identity Card Number *

Email *

Numbor Telefon/Phone Number *

Jantina/Gender *

Lelaki/Male
Perempuan/Female

Keturunan/Race *

Adakah anda berkerja sekarang? / Are you currently working? *

Ya/Yes
Tidak/No

Jenis Pekerjaan/Type of Work *

Alamat/Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Status Merokok / Smoking Status *

Masih merokok / Current smoking
Sudah berhenti merokok / I have stopped smoking
Tidak pernah merokok / I have not smoke

Percubaan berhenti merokok pada masa lalu/Attempt to Quit Smoking in the past *

Tidak Pernah/Never
1-2 kali/times
3 kali dan lebih/3 or more times

Berapa kali anda merokok dalam sehari, masa kini / How many times you smoke in a day? *

Umur berapakan anda mula merokok / At what age did you start smoking *

Berapa tahun anda sudah merokok? / How many years have you smoke? *

Commit to Quit - Quit Now *

Saya berjanji untuk berhenti merokok / I promised to quit smoking

Tanda tangan peserta / Signature of Participants *

Nama Saksi / Name of Witness *

No Kad Pengenalan Saksi / Witness' Identity Card Number *

Alamat Saksi / Witness' address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Konsent Pelindungan Data Peribadi / Personal Data Protection Consent *

Saya setuju dengan policy Pelindungan Data Peribadi / I agree with the data protection policy

Dengan mengemukakan borang ini, saya bersetuju bahawa ASH MMA - Action on Smoking and Health boleh menggunakan, menyimpan dan memproses maklumat untuk tujuan kempen Commit to Quit-Quit Now! By Submitting this Form, I hereby agree that ASH MMA – Action on Smoking and Health to use, store and process the information for the purpose of the Commit to Quit – Quit Now! campaign.