check list A - 4

SPECIMEN SIGNATURES OF AUTHORISED SIGNATORIES

(To be typed on Applicant Company’s Original Letterhead)
MUST BE UPDATED ANNUALLY ON JANUARY 1 AND
WHENEVER THERE ARE CHANGES DURING THE YEAR

Date of Issuance :

The Executive Secretary

Kedah Chinese Chamber Of Commerce And Industry
749, 2nd Floor, Lebuhraya Darul Aman,
05000 Alor Setar, Kedah Darul Aman.

Dear Sirs

Signatures of Authorised Signatories for the Application, Certification and Endorsement of

Certificate of Origin/Other Shipping Documents

VALID FROM JANUARY 1 / OR CURRENT DATE, 2018 TO DECEMBER 31, 2018

We confirm that the respective persons named below have been authorized by *the board of
directors/the sole proprietor/partners of the *company/firm to make applications, for and on our
behalf, for Certificates of Origin or Endorsements or Certifications on Certificates of Origin; to sign all
Certificates of Origin and other supporting or shipping documents whatsoever and to issue letters of
indemnity in your favour in relation thereto. The authorizations of the respective persons named below
have not been revoked and you are entitled to treat such authorizations as remaining valid unless you
receive written confirmation from us that any or all of such authorizations has or have been revoked by
the *board of directors/sole proprietor/partners of the *company/firm:

Name I/C Number Designation Signature

Submitted by:
Company
______________________________ Official
Signature of CEO / Managing Director / Director / Senior Manager / Manager Rubber Stamp

________________________________
Full Name of CEO / Managing Director / Director / Senior Manager / Manager

________________________________
Designation
*To delete accordingly

Check list A - 6
Date: 1st January, 2018 / or current date

SAMPLE OF STATUTORY DECLARATION

(Statutory Declaration should be typed using Company letterhead)

STATUTORY DECLARATION

I __________ (name of applicant) (NRIC No._____________) of ____________ (address) do hereby

affirm and solemnly declare the following:

1. That I am __________(position in Company) in ____________ (Company name and address) and am

duly authorised to affirm this declaration on behalf of the Company;

2. I make this declaration in full knowledge and awareness of your reliance on this declaration as an
inducement or basis to endorse/certify on document(s) presented by our Company;

3. I undertake and agree to fully indemnify the Kedah Chinese Chamber Of Commerce And Industry
(KCCCI) in full from and against all consequences, liabilities, actions, suits, proceedings, damages, costs,
claims, demands, expenses, or losses whatsoever which may be taken or made against you or incurred or
become payable by you by reason of or on account of or arising out of your issuing, endorsing or certifying
the aforesaid documents;

4. I am fully aware that it is a criminal offence to induce you to endorse on our documents on the basis of a
false declaration;

5. I am also aware that the penal consequences for a false declaration in respect of the above may include:

(a) imprisonment for a term not exceeding three (3) years and shall also be liable to a fine pursuant to
Section 193 of the Penal Code read together with Section 199 or 200 of the Penal Code; or

(b) imprisonment for a term not less than one (1) year and not exceeding ten (10) years and with whipping
and shall also be liable to a fine pursuant to Section 420 of the Penal Code;

(c) fine not exceeding RM500,000.00 (Five Hundred Thousand Ringgit) or to imprisonment for a term not
exceeding (5) five years or to both under Section 133 of Customs Act 1967.

And I make this solemn declaration conscientiously believing the same to be true and by virtue of the
provisions of the Statutory Declaration Act, 1960.

Subscribed and solemnly )

declared by the above named )
)
in the State of ) …………………………………………
on this day of ) signature of applicant
(CEO/Managing Director/Directors of the Company)

Before me,
Company Official Rubber
…………………………………………. Stamp
COMMISSIONER FOR OATHS

** ps. This Statutory form is to be affirmed only by CEO / Managing Director / Directors of the Company
 Check list A -7
Specimen Standard Letter of Indemnity
(Letter of Indemnity should be typed under company letterhead)

Date of issuance :

The Executive Secretary

Kedah Chinese Chamber Of Commerce And Industry
749, 2nd Floor, Lebuhraya Darul Aman,
05000 Alor Star, Kedah Darul Aman.

Dear Sirs

Letter of Indemnity

In consideration of your issuing, endorsing or certifying at our request such certificates of origin,
commercial invoices, packing lists and all other documents whatsoever required of you by us during
the period of (Current date/Invoice date)* to 31st December, 2018 , we hereby undertake to fully
indemnify you and to keep you fully indemnified against all actions, suits, proceedings, claims,
expenses, loss, damages, costs, charges and liabilities whatsoever which may be taken or made against
you or incurred or become payable by you by reason of or on account of or arising out of your issuing,
endorsing or certifying the aforesaid documents.

We declare and confirm that the information contained in all our applications for any such certificates
or certifications as referred to above is true and correct.

Yours faithfully

__________________________________
Signature of CEO / Managing Director / Director / Senior Manager / Manager

__________________________________
Full Name of CEO / Managing Director / Director / Senior Manager / Manager

__________________________________
Designation

__________________________________
Identity Card No. of CEO / Managing Director / Director /Senior Manager / Manager

RM10.00 Revenue
Stamp stamped at
the Government
Stamping Office

Company’s Official Rubber Stamp

Note :
* To delete accordingly
Check List B - 2
Specimen Standard Letter of Indemnity Covering Third Party Consignor
(Valid On Per Shipment Basis)
(Letter of Indemnity should be typed under company letterhead)

Date of issuance :

The Executive Secretary

Kedah Chinese Chamber Of Commerce And Industry
749, 3rd Floor, Lebuhraya Darul Aman,
05100 Alor Star, Kedah Darul Aman.

Dear Sirs
Letter of Indemnity

We hereby request you to endorse the attached certificate of origin and/or other related shipping
documents listing (name & address of 3rd party consignor) as consignor in lieu of (name of company
issuing this letter of Indemnity) covering shipment as stated below :

Invoice No and Date :

Mother vessel :
Feeder vessel :
ETD :
Port of loading :
Port of discharge :

In consideration of your issuing, endorsing or certifying at our request such certificates of origin,
commercial invoices, packing lists and all other documents whatsoever required of you by us in
respect of the above shipment, we hereby undertake to fully indemnify you and to keep you fully
indemnified against all actions, suits, proceedings, claims, expenses, loss, damages, costs, charges and
liabilities whatsoever which may be taken or made against you or incurred or become payable by you
by reason of or on account of or arising out of your issuing, endorsing or certifying the aforesaid
documents.

We declare and confirm that the information contained in all our applications for any such certificates
or certifications as referred to above is true and correct.

Yours faithfully

_________________________________ Company’s
(Signature of Authorized Signatory) Official
Rubber
_________________________________ Stamp
(Full Name of Authorized signatory)

_________________________________
(Designation of authorized signatory)