KE M

HTERIAN IGUI'AI,I GAN MALAY$ IA

(Borang Pengesahan Akaun Bank Syarikat)

Nama

Syarikat

No. Pendaftaran

ROC/ROB/ROS

Setiausaha,

Bahagian Perolehan Keraj aan,

Tingkat Bawah, Blok Utara,
Kompleks Kementerian Kewangan,
Presint 2,
Fusat Pentadbiran Keraj aan Persekutuan
62592 Putrajaya
Tel: 03-88823000
Tuan,

Nama Bank
Cawangan Bank

Alamat Bank

Poskod

?.9,.?eQ

No. Akaun

E5.0s15.1!q?l-1
PENAI\DATANGAN CEK

Adalah diakui bahawa rutma-nama berikut telah diberi kuasa oleh syarikat untuk menandatangani
cek akaun di atas:

Nama & No. K/P

No.

>aini bri Nr'

Tandatansan

,#"*&^*

Uo U,P ? >a>oZ -O 8 - te 39

Terme dan keadaan untuk tandatangan cek

j41Y.
rarikh. \b

[r [*tb

Disahkan Oleh:

PU/UPSl1-v.1/10(Br)

DECTARATION FORM FOR REGISTRATION OF COMPANY/CONSUTTING FIRM WITH

THE MINISTRY OF FTNANCE MALAYSIA
Application Reference No
Application Type

Declaration For Appllcatlon To Register

llllth

The Mlnlstry

Of

Flnance Melrysla

l.

l/We declare that submisslon of all information in thh declararion form, application form and supporting documents ls correct and valld.
l/We hereby allow the Ministry of Finance to veriff any informatlon ln this declaration form, appllcation form and supporting documents
wlth the company/consultlng flrm or any other thlrd party. l/We agree that l/we am/are responslble to update any changes in the
company's lnformation lf ann after regstration withln
occur. If l/we fall to do so, the
Ministry of Finance Malaysia may cancel the registratlon or

2.

I/We consent to the Mlnlstry of Flnance Malaysia representatlve rc vlsit the company/consultlng flrm premises for the inspectionlaudlt
purposes and to verifr the documents and related lnformation.

3.

l/We declare that the company/consultlng flrm does not have Owners, Board of Dlrectors/Direcon, Managers and Employees ln any
company/consulting ftrm who have been registered with the Ministry of Finance in the same category/categories. l/We agree that only
perconnel authorlzed by the company/consulting ftrm and the names stated ln the Company/Consulting Firm Reglstratlon Cenlflcate are
allowed o do any transactlon in Govemment procurement on behalf of the company/consultlng firm.

4-

l/We agree that fte company/consuldng frrm after belng newly registered li not allowed to make any changer to Equlty OwneBhlp and
Board of Directors/Managers within sk (6) months ftom the date of reglstratlon.

5.

l/We allow the Ministry of Finance Malaysia to provide information of the company/consulting firm to other Agency/Agencies for the
purpose of Government procurement and to third party/pardes for the purpose of improving the Govemment delivery sy$em.

6.

I/We understand tfiat fallure to comply wlth any of the above condltlons, the Mlnlstry of Flnance Malaysla has"the rlght to relect the
company/consulting firm's application. If the appllcation is reiected, the do(rments submhted will be returned by posVcourier except
when requested by the company/consulting firms, the documents will be ield temporarily for founeen ( l4) days from the date of
reiection. The document wlll return by mail lf they remain unclaimed wlthin this period.

7.

l/We understand that whatever documents submitted for registratlon wlll become the Government property for any appllcations tfiat
sr reiected after the visit/audit.

have been approved

d.

l/We agree to glve permlslon to the Mlnistry of Flnance Malaysla to cancel the reglstratlon and delete all records/data automatically
ftom the ePerolehan system lf l/we do not renew the company/conruhlng flrm reglstradon dthin one ( I ) year from the expiry date of
speciry reglstration. l/We may make a new appllcadon lf sdll lnterested to reglster with the Ministry of Finance Malaysla after the period.

9.

l/We undersund that the Government and the Minlstry of Finance Malaysia is not responslble for any loss(es) or damage(s) on the
company /consulting flrm that have been rglrtered with the Mlnlstry of Flnan(e Malaysia and/or use any lnformation obtalned from thls
website: www.eperolehan.gov,rry. l/We also agree that the approval of reglstration will not in any way bind the Govemment to offer any
Government procurement to the company/consulting firm.

10.

l/We understand that any act or attempt to comrptly offer or give, sollcit or receive any gratiftcation to and from any person relating
Govemment procurement h a crlmlnal offence under the Malayslan Anti-Comrption Cornmission Act 2OO9 [Act 6941. lf any indMdual
attempts to seek bribe from the compaflconsulting firm as an offer/or gratification pertainlng to Government procurement, l/we will
immediately lodge a report at the nearest offfce of the Malaysian Antl-Comrption Commlslon (MACC) or pollce satlon.

Slgnature

/,

,l

:T?-,

Applicant's Name"

Aaui

Vrrvr

NRIC/Paspon No.

'lrouog

Atp l-\a!8a'r
bggt

Designatlon

Name of Company/Consultlng
Flrm
Date

* Notes: To

Official Seal Of
Company/Consultlng
Firm

!an& lcv rvrela [o{r-r"pv.9ttt, lq l)alL

be slgned by Ovmer/Direcor/Manager

of the company/consultlng ffrm which have been declared in the ePerolehan System onty.