PERSATUAN PENGIMPOT & PENIAGA KENDERAAN

MELAYU MALAYSIA(P E K E M A)

APPLICATION FORM:PEKEMA REGISTERED SUPPLIER

NO A12a-3, JALAN SELAMAN 1/1, DATARAN PALMAJALAN AMPANG, 68000 AMPANG

SELANGOR DARUL EHSAN

TEL : 603 42702144, 42702146, 42702155 FAX : 603 42702172

PART 1

REGISTRATION BY COMPANY TO SUPPLY VEHICLES TO PEKEMA MEMBERS.

1.1 Name of Company :

……………………………………………………………………………………..........................................

1.2 Registered Address:

………….......................................................................................................................

……………………………………………………………………………..................................................

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1.3 Office Address :

………………………………………………………………………………...............................................

…………………………………………………………………………....................................................

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1.4 Telephone No : …………………………………………………..........................

1.5 Fax No : ……………………………………………….............................

1.6 Email Address : ………………...............................................................

1.7 Website Address : ................................................................................

1.8 Date of Incorporation : ……………………………………………………………................

1.9 Business Registration No : ……………………………………………………………................

1.10 Authorised Capital : ...............................................................................

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1.11 Paid Up Capital : ...............................................................................

1.12 Shareholders :

Name Pasport No Percentage of Shares held

1. …………………………….........…… ……. …….................................. ......…............%

2. …………………………………………....... ....................................... ......…............%

3. ………………………………...............… ….................................… ......…............%

1.13 Board of Directors:

Name Passport No

1 …………………………………........................... …………………...................…..

2. .……………………...........................…………… …………………........................

3. ………………………………............................. ……………………......................

*Add if necessary

PART II

FINANCIAL INFORMATIONS

2.1 Banks

Name of Bank :

………………………………………………………………….………………..............................

Address:

…………………………………………………………………..................................……………

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………………………………………………………………….......………………........................

…………………………………………………………………..................................……………

Current Account No: .................................................................................PART III

3.1 APPLICATION PROPOSED BY :

1. Name of Proposer : ……………………………………………………………….

Position in Company : …………………………………………………….....………

Company’s Name : …………………………………………….………............

PEKEMA Membership No : ………………………………………….........…............

Chop & Sign : ....................................................................

2. Name of Proposer : ……………………………………………………………….

Position in Company : …………………………………………………….....………

Company’s Name : …………………………………………….………............

PEKEMA Membership No : ………………………………………….........…............

Chop & Sign : ....................................................................

3. Name of Proposer : ……………………………………………………………….

Position in Company : …………………………………………………….....………

Company’s Name : …………………………………………….………............

PEKEMA Membership No : ………………………………………….........…............

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Chop & Sign : ....................................................................

Note:

3.2** PLEASE ATTACH:

1) COMPANY’S PROFILE2) COPY OF COMPANY REGISTRATION 3) RECOMMENDATION LETTER FROM AP HOLDER

3.3 I declared that the informations given above are correct. I Understand and accept that if they are found to be inaccurate or false, my application and subsequent registration can be terminated by PEKEMA.I do hereby agree that if this application is accepted, that we will abide by all the terms & conditions set up pertaining to this registration, failing which our registration shall be terminated by PEKEMA.

Signature : ……………………………………………………………

Name : …………………………………………………………….

Position : …………………………………………………………….

Company Seal/ Chop : ……………………………………………………….......

Date : ……………………………………………………….......

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FOR PEKEMA OFFICIAL USE ONLY

Application Approved / Not Approved:

Comments : ……………………………………………………………………………......................................…

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Date : ....................................... .............................................. President of PEKEMA

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