DETAILS OF COLLABORATORS FOR MAK CIK PC



|Type of Registration [Please tick (√) the appropriate box] |

|New |

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|Existing |

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VENDOR REGISTRATION FORM

(This form must be fully completed by VENDOR. Write ‘Nil’ or ‘N/A’ (not applicable) where appropriate)

|1. Company Name |: | |

|2. Company Reg. No. |: | |3. Business Operating Address |

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| | | |Country : _________________ Post Code : _______________ |

|4. Contact Person |: | | |

|5. Designation |: | | |

|6. Phone No. |: | | |

|7. Fax No. |: | |10. Date of Incorporation |: | |

|8. H/P No. |: | |11. Authorized Capital |: | |

|9. Official E-Mail |: | |12. Paid Up Capital |: | |

| | | |13. Working Capital |: | |

|14. Shareholding Structure |: |(Please state in terms of %) |

| | |a. Bumiputra Contents | |

| | |b. Non-Bumiputra Contents | |

| | |c. Foreign Contents | |

| | |Total |100% |

|15. Company Directors : |

|(A certified true copy of Form 49 must be attached with this completed form) |

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|Note : Please use additional papers if the above space is inadequate |

|_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ I/C / Passport Number:- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ |

|_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ I/C / Passport Number:- _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ |

|_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ I/C / Passport Number:- _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ |

|16. Organization Type : [Please tick (√) the appropriate box] |

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|1. Sdn. Bhd. |

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|2. Berhad |

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|3. Corporative |

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|4. Enterprise |

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|5. Partnership |

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|6. Sole Proprietorship |

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|17. Work Category : Limited to ten (10) main category only |

|Note : Refer to Work Categories Listing attached. Please tick (√) the appropriate box. |

|18. Company’s Registration : |

|Registered with : [Please tick (√) the appropriate box] |

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|a |

|Kementerian Kewangan Malaysia (MOF) |

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|f |

|Jabatan Bekalan Elektrik (JBE) |

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|b |

|Board Of Engineers Malaysia (BEM) |

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|g |

|Board Of Architect (BOA) |

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|c |

|Pusat Khidmat Kontraktor (PKK) |

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|h |

|Suruhanjaya Tenaga (ST) |

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|d |

|Kementerian Dalam Negeri (KDN) |

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|i |

|Others (please specify) |

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|e |

|Construction Industry Development Board (CIDB) |

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|j |

|Not applicable (N/A) |

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|19. No. of Employee : _____________ |20. Preferred Banker |

|21. Type Of Office | _______________________________ |

|Own |Account Number:- |

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|Rental | |

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| |________________________________ |

|22.0 |COMPANY’s DECLARATION | | |

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| |22.1 |The undersigned hereby declare that all particulars contained in this completed form and all duplicate copies of certificates, |

| | |letters and document attached herewith are true and accurate, and there has been no deliberate suppression of facts which are |

| | |required for the completion of this form. |

| | | |

| |22.2 |The undersigned agreed that MIMOS Berhad be granted the right to contact our clients on our company’s performance and also to |

| | |verify independently, our company’s financial standings with our banks. |

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| |22.3 |The undersigned also agreed to allow employees or representative of MIMOS Berhad to visit our company and inspect all the |

| | |particulars furnished in the form. |

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| |22.4 |The undersigned fully understand that no consideration will be granted to our company if any of the particulars are found false|

| | |and incorrect. |

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| |22.5 |The undersigned accept that our company will be liable to instant de-registration without notice if :- |

| | |(i) |Any particulars subsequent to our registration are found to be false and incorrect; |

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| | |(ii) |Our company fails to notify immediately MIMOS Berhad on any change in the shareholding and/or any major changes in our|

| | | |company’s organization structure; and |

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| | |(iii) |Our company generally appears in the market as practicing unprofessional business ethics. |

| |AUTHORISED SIGNATORY |: | | |

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| |NAME |: | | |

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| |DESIGNATION |: | | |

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| |DATE |: | | |

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| |COMPANY STAMP |: | | |

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(*) MIMOS BERHAD INTERNAL USE:-

For one time / direct payment purpose only:-

I hereby signed on behalf on the company and shall liable of any false and incorrect information stated in the form.

| |SIGNATORY |: | | |

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| |NAME |: | | |

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| |DESIGNATION |: | | |

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| |DATE |: | | |

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VENDOR REGISTRATION CHECKLIST

[Please tick (√) the appropriate box]

|Mandatory Supporting Documents for Local Company | |

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|1 |Company Profile (Organisation Chart, Services Offered, Product Information & catalogue) | |

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|2 |Certificate of Registration with Government Bodies, Private Sectors and Public Sectors. | |

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|Additional Documents for Private Limited and Public Limited Company |

|1 |Form 9 / Form 13 | |

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|2 |Form 24 – Return of Allotment of Shares. | |

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|3 |Form 32A – Transfer of Shares | |

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|4 |Form 49 – Latest Particulars of Directors, Managers and Secretaries. | |

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|5 |Audited Account for the last Financial Year | |

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|Additional Documents for Sole Proprietor |

|1 |Form B - Business Information & Current Owner | |

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|2 |Form D – Registration Confirmation | |

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|3 |Income Statement & Balance Sheet for the last Financial Year | |

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|Additional Documents for Partnership |

|1 |Form A or Certificate of Registration | |

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|2 |Income Statement & Balance Sheet for the last Financial Year | |

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|Preferable Supporting Documents for Non Local Company | |

|1 |Oversea Certificate of Registration. | |

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|2 |Memorandum of Article (M & A) | |

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|3 |List of directors | |

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|4 |Audited Account for the last Financial Year | |

|Safety Management System | |

|1 |Organization chart reflective to the safety commitment | |

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|2 |Safety policy manual | |

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|3 |Safety training provided to the staff | |

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