BORANG PENYERTAAN PENSIJILAN THE BLUE RIBBON CAMPAIGN

1. NAMA & ALAMAT PREMIS: NAME & ADDRESS OF PREMISES: MAKLUMAT PEMILIK/PENGHUNI PREMIS: INFORMATION OF OWNER / RESIDENT OF THE PREMISES 2.1 2.2 2.3 2.4 2.5 2.6 2.7 3. Nama Pemilik/Penghuni/Ketua Jabatan : Name of owner/ tenant/ Head of Department: No. Kad Pengenalan : IC No No. Pendaftaran Syarikat (jika berkaitan): Registration no (if applicable) No. Lesen Pihak Berkuasa Tempatan (jika berkaitan): Local Authority Government License No (if applicable) No. Telefon dan No. Fax : Telephone No and Fax No: Alamat laman web (jika ada) : Website address (if any) Alamat email (jika ada) Email address (if any)

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MAKLUMAT PEGAWAI BERTANGGUNGJAWAB DI ORGANISASI INFORMATION OF OFFICER IN CHARGE IN ORGANIZATIONS 3.1. Nama Pegawai : Name of Officer 3.2 Jawatan : Position 3.3 No.Telefon Pejabat: Office Telephone No. 3.4 No. Telefon bimbit : Mobile Phone No 3.5 Tandatangan pegawai : Officer Signature: 3.6 Cop jabatan/ organization : Department/ organization stamp Borang permohonan ini perlu dikemukakan ke alamat berikut pada atau sebelum .........: Application form must be submitted to below address on or before ....... Urusetia The Blue Ribbon Campaign Lembaga Promosi Kesihatan Malaysia (MySihat) Aras 9, 11 & 12, Menara Prisma, 26 Boulevard, Persiaran Perdana, Presint 3, 62675 Putrajaya No. Telefon : 03-8888 7700

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No.Fax

: 03-8888 7402