OPS-FO-01-005

Rev.3

DECLARATION FOR RELEASE OF LIABILITY, UNDERTAKING & AUTHORISATION

FOR THE PURPOSE OF VEHICLE INSPECTION
(TO BE FILLED BY REGISTERED VEHICLE OWNER)

1. I / We ………………………..………………………………….……………………IC No./Company No. : ……...……………………………………….

(Name as per in Identification Card)

(“Vehicle Owner”) for Vehicle Registration No………………..………………………………………………………….. (“Vehicle”) hereby declare : -

(Registration / Chassis No.)

(a) that based on my / our knowledge, this Vehicle is not a stolen vehicle and there is no modification / tampering / cut & joint made on
this Vehicle without the approval of the Road Transport Department (RTD) (including and not limited to engine number and/or
chassis number of this Vehicle);
(b) understand and accept the conditions of service for vehicle inspection as follows:
i. If this Vehicle does not comply with the Road Transport Act 1987, the Motor Vehicles (Periodic Inspection, Equipment and
Inspection Standard) Rules1995 or amendments thereto, and/or any relevant laws on such inspections, PUSPAKOM
reserves the right to fail the inspection of the Vehicle and make reference to the relevant government departments/agencies
for further investigation.
ii. PUSPAKOM Inspection Report/Certificate is issued based on the Vehicle condition at the time the vehicle inspection is
conducted by PUSPAKOM.
iii. to fully discharge, release and hold harmless PUSPAKOM from and against any and all liability, claims, causes of action,
proceedings, demands, damages (including costs and expenses related thereto) that I have against PUSPAKOM in any way
relating to or arising from the vehicle inspection (including without limitation relating to injury, accident, illness, disability,
death, loss, damage or expense of any kind).
iv. to undertake not to engage in corrupt activities (directly or indirectly) involving vehicle inspection services at PUSPAKOM.
v. that any complaint regarding the service must be made by the Vehicle Owner accompanied with the original copy of the
Inspection Report / Certificate issued by PUSPAKOM.
vi. that I am aware that the following are the applicable rates of inspection fee:
No. Type of Inspection Inspection Fee*
1. Initial From RM 40.00 to RM 90.00 depends on the type of vehicle
2. Periodic From RM 35.00 to RM 75.00 depends on the type of vehicle
3. Transfer Ownership RM 30.00 for all type of private vehicles
4. Special From RM 20.00 to RM 50.00 depends on the type of vehicle
5. Hire Purchase RM 60.00 for all private & company vehicles
6. Others Please refer www.puspakom.com.my or contact 1800 88 6927
*Fee published is subject to change and Sales and Services Tax shall be applicable thereto.
*For Mobile Services, a service charge will be applicable.

THIRD PARTY AUTHORISATION

(TO BE FILLED BY REGISTERED VEHICLE OWNER)

2. I / We hereby authorize ………………………………………………………………………………………………

(Name as per Identification Card)

IC No. .............................................................. to act on my behalf during the vehicle inspection at PUSPAKOM. I / We shall be solely
responsible for my/our Representative and such Representative shall abide to paragraphs (1)(a) and (1)(b) above.

Signature (Owner) : ………………………………………….………………….……… Date: ….......……………………………………

Address (Owner) : …………………………………………..……………..……………………………………………………………..…
……………………………………………………..………………………………………………………………...…
Tel. No. & E-mail (Owner) : ………………………………………………………………………….………………………………………………
Company Stamp (Owner) :

PRIVACY NOTICE You are hereby notified that PUSPAKOM is in compliance with the requirements of the Personal Data Protection Act (PDPA) 2010.
Your personal data provided to PUSPAKOM or obtained through government departments/agencies is intended for us, our agents and/or authorities is to
enable us to provide our services to you and you hereby consent to the use of such data. For further inquiries please refer to www.puspakom.com.my
website