NAME 名字*

MOBILE NUMBER 手机号码*

EMAIL 电子邮件地址*

POSTAL CODE (RESIDENCE) 居住地邮政编码*

1. Who are you planning the funeral for? 您打算为谁举办丧礼?*
—Please choose an option—Myself 自己My Wife 我妻子My Husband 我先生My Father 我父亲My Mother 我母亲My Son 我儿子My Daughter 我女儿My Paternal Grandfather 我祖父My Paternal Grandmother 我祖母My Maternal Grandfather 我外祖父My Maternal Grandmother 我外祖母My Father-in-Law 我岳父My Mother-in-Law 我岳母Others 其他

2. Where is the person you are planning for residing (postal code)? 目前的住址邮区号?*

3. What is his/her medical condition? 现在的健康状况如何?*
—Please choose an option—Medical prognosis: < 1 month of life 医学预后: 少过一个月生命Medical prognosis: < 1 month to 3 months of life 医学预后: 一至三个月生命Medical prognosis: < 3 months to 6 months of life 医学预后: 三至六个月生命Medical prognosis: < 6 months to 1 year of life 医学预后: 六个月至一年生命Healthy and sound 身体健康

4. What is the reason for preplanning? 提前规划的原因是什么?*

5. How many days of wake? 打算停丧几日?*
—Please choose an option—3 days 3天5 days 5天≥7 days 7天

6. Where do you want to hold the wake? 理想的停丧地点?*
—Please choose an option—HDB void deck 政府组屋楼下Funeral parlour 殡仪馆Landed property 私宅Open space 开放空间

7. How many guests will be expected at the wake per day? 预估探丧亲友人数?*
—Please choose an option—Less than 30pax 30人以下50pax-100pax 50-100人100-200pax 100-200人>200 pax 200人以上

8. Have you decided on Cremation or Burial? 您选择火葬或土葬?*
—Please choose an option—Cremation 火葬Burial 土葬

9. Where do you want your final resting place to be? 希望安息的地点?*
—Please choose an option—Algordanza Memorial Diamond 雅歌丹砂钻石Sea burial 海葬Inland Ash Scattering Facility (CCK) 骨灰撒土 (蔡厝港）15 Years Burial lease at Choa Chu Kang Cemetery 蔡厝港公墓15年埋葬租约Government columbarium Mandai 政府万礼骨灰安置所Government columbarium Choa Chu Kang 政府蔡厝港骨灰安置所Buddhist temple 寺庙Taoist temple 道观Church 教堂Private Columbarium 私人骨灰安置所Not decided yet 尚未决定

10. What religious rites do you need? 丧礼的宗教仪式?*
—Please choose an option—Buddhist 佛教Taoist 道教Christian 基督教Catholic 天主教Freethinker 无宗教信仰Others 其他

What language do you prefer? 您选择的语言是?*
—Please choose an option—English 英文Mandarin 中文English or Mandarin 中英文皆可

When would you like a call back from us? 您希望我们什么时候回复电话?*
—Please choose an option—Today 今天Within 3 days 三天之内Within 7 days 七天之内

Which timing would you like a call back between? 您方便谈话的时间?*
—Please choose an option—10am-12pm12pm-2pm2pm-4pm5pm-7pm7pm-9pm

MESSAGE

By submitting this form, you consent to the subsidiaries of Ang Chin Moh Group to contact you (even though your Singapore telephone number is already registered on the National Do Not Call Registry) for marketing purposes, and provide you with marketing, advertising and promotional information, materials and/or documents relating to funeral planning services and events organised by subsidiaries of Ang Chin Moh Group. The consent you provide is in addition to and does not supersede, vary or nullify any consent which you may have provided previously in respect of the above purposes, unless your previous consent has been withdrawn. You also confirm that you are the user/or subscriber of the Singapore telephone number and email address provided by you. 提交此表格即表示您同意洪振茂集团的子公司出于营销目的联系您（即使您的新加坡电话号码已在全国谢绝来电登记处登记），并向您提供营销、广告和促销信息，与洪振茂集团子公司组织的丧礼策划服务和活动相关的材料和/或文件。您提供的是对您先前就上述目的提供的任何同意的补充，不取代、更改或无效，除非您先前的同意已被撤回。您确认您是提供新加坡电话号码和电子邮件地址的用户/订户。