Company Reference

Sila lengkapkan boring ini dengan HURUF BESAR menggunakan pen dakwat hitam / Please complete this form in CAPTIAL LETTERS with black ink.

1.0

MAKLUMAT PERIBADI / INDIVIDUAL PARTICULARS

Nama Penuh / Full

Name

No.K.P./NRIC No.

Umur / Age

Tarikh Lahir / Date of Birth (dd/mm/yyyy)

No.KP. Lama/Polis/Tentera/No. Pasport / Old NRIC/Police/Army/Passport No.

Alamat / Address
Phone Number
Home
Office
Personal

2.0

BUSINESS DETAILS

Registration Number (company)

Company Name
Company Address
/ Post Code
Contact Number
Company
Fax Number

3.0

RELATIVES / GUARDIANS

Name
ID Number
Date of

Birth

Correspondence
Address / Post Code
Phone Number
Home
Office
Personal

4.0

DETAILS ON SHOP / MART

Location
Address
ETC
ETC
ETC

5.0
ETC
ETC

LICENSING DETAILS / CHECKLIST

(mm/dd/yyyy)

Age

ETC