NanoWash

TM

APPLICATION FORM
TO BECOME AN OUTLET OWNER
FOR NANOWASH™ BRANCH
REMINDER
1. PLEASE READ THE GUIDELINES CAREFULLY BEFORE FILLING IN THIS FORM
SILA BACA PANDUAN SEBELUM MENGISI BORANG INI

2. PLEASE COMPLETE THE FORM IN A TYPEWRITTEN FORMAT

SILA ISI BORANG DENGAN LENGKAP DENGAN MENULIS MENGGUKAN HURUF BESAR

3. PLEASE ATTACH ALL NECESSARY DOCUMENTS

SILA KEPILKAN DOKUMEN YANG BERKAITAN

4. INCOMPLETE APPLICATIONS WILL BE REJECTED

BORANG YANG TIDAK LENGKAP AKAN DITOLAK PERMOHONAN

5. THE FORM HAS TO SUBMITTED TOGETHER WITH A PROCESSING FEE & BOOKING FEE OF
PAYMENT CAN BE MADE TO “ MIRESCO INTEGRATED SDN BHD” AT THE FOLLOWING ADDRESS :
BORANG HARUS DIHANTAR DENGAN YURAN PROSES DAN BAYARAN BOLEH DIBUAT KEPADA “MIRESCO
INTEGRATED SDN BHD” DI ALAMAT BERIKUT

ATT : PUAN MASHETAH JAMIL

MIRESCO INTEGRATED SDN BHD (658764-K)

Level 36, Menara Citibank, 165, Jalan Ampang
50450 Kuala Lumpur, Malaysia
Tel : +603.2169.7360
Fax : +603.2169.7361

FOR OFFICE USE

PAYMENT RECEIVED OFFICER’S

DETAILS SIGNATURE
PROCESSING & BOOKING FEE LICENSE FEE

Date Received

Crossed Cheque, Postal order, money

order or bank draft number and date

Receipt No./date

NanoWash™ License No

PRIVATE & CONFIDENTIAL . Copyright © 2009. Miresco Integrated Sdn Bhd. All right reserved. Version 1.1-260609
 MIRESCO INTEGRATED SDN BHD (658764-K)
Level 36, Menara Citibank, 165, Jalan Ampang 50450 Kuala Lumpur, Malaysia

NanoWash
TM Tel : +603.2169.7360 Fax : +603.2169.7361

Branch Office
No 49-A, Jalan Lawan Pedang 13/27, Section 1340100 Shah Alam, Selangor, Malaysia
Tel : +603.5510.0607 Fax : +603.5510.0608

NANOWASH OUTLET PROGRAM APPLICATION FORM

This Application is kept confidential. Neither party is bound in any way by the submission of this Application. This Application must be completed in full and returned to receive further
contact and information from MIRESCO INTEGRATED SDN BHD. Please type or print clearly and attach additional documents or schedules, if necessary, to provide full disclosure.

PERSONAL INFORMATION
Title
Gelaran Mr Mrs Ms

Full Name
Nama Penuh

New IC No Passport No.

No. K/P Baru No Paspot
Old IC No Date of Birth
No. K/P Lama Tarikh Lahir
Home Address
Alamat Rumah

City State
Bandar Negeri
Years there Citizenship
Tahun menetap Warganegara
Res No. Mobile No.
No. Tel. Rumah No. Tel. Bimbit
Email
Emel

Residence
Kediaman Own Parents' Rented Relatives' Others
Marital Status
Perkahwinan Married Single

EMPLOYMENT DETAILS
Name of Employer
Nama Majikan

Office Tel Ext Office Fax

No. Pejabat Samb Faks Pejabat
Office Address
Alamat Pejabat

Nature of Business
Jenis Perniagaan

Designation Years employed/in business

Jawatan Tempoh bekerja/perniagaan
Bs. Classification
Jenis Perniagaan Sole Proprietorship Partnership Sdn Bhd Government Others

EDUCATION BACKGROUND
High School Major Year
Sekolah Menengah Khusus Tahun

College/University Major Year

Kolej/Universiti Khusus Tahun

College/University Major Year

Kolej/Universiti Khusus Tahun

College/University Major Year

Kolej/Universiti Khusus Tahun

Certificate
Sijil

Diploma/Degree
Diploma/Ijazah

Master/PHD
Ijazah/PHD

Others
lain-lain

PRIVATE & CONFIDENTIAL . Copyright © 2009. Miresco Integrated Sdn Bhd. All right reserved. Version 1.1-260609
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 SPOUSE INFORMATION
Full Name
Nama Penuh

New IC No Passport No.

No. K/P Baru No Paspot
Old IC No Date of Birth
No. K/P Lama Tarikh Lahir
Name of Employer
Nama Majikan

Office Tel Mobile No.

No. Pejabat No. Telefon Bimbit
Office Address
Alamat Pejabat

Nature of Business Years employed/in business

Jenis Perniagaan Tempoh bekerja/perniagaan
Designation Annual Income
Jawatan Pendapatan Tahunan

PERSONAL REFERENCE (Nearest relative not living with you)

Name
Nama

Relationship
Hubungan

Address
Alamat

Res No. Office Fax

No. Tel. Rumah Faks Pejabat
Mobile No.
No. Tel. Bimbit

PERSONAL FINANCIAL STATEMENT

Sources of Income
Sumber Pendapatan Annual Salary Real Estate Income

Bonus Business Profits TOTAL ANNUAL RM

INCOME

Divident/Interest Spouse Income

BANKING REFERENCES
First Bank Location
Bank Pertama Lokasi
Account No. Type of Account
No. Akaun Jenis Akaun

Second Bank Location

Bank Kedua Lokasi
Account No. Type of Account
No. Akaun Jenis Akaun

Third Bank Location

Bank Ketiga Lokasi
Account No. Type of Account
No. Akaun Jenis Akaun

PRIVATE & CONFIDENTIAL . Copyright © 2009. Miresco Integrated Sdn Bhd. All right reserved. Version 1.1-260609
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OUTLET PARTICULARS & INFORMATION
How will you finance this business venture? Cash Loan Grant
Bagaimana cara pembayaran anda untuk perniagaan ini?
RM RM RM

Choose Your Package START-UP WET & WASH START-UP DRY CLEANING UPGRADE WET & WASH UPGRADE DRY CLEANING
Pilih Pakej anda
Amber I Diamond I Amber II Diamond III

Pearl I Diamond II Pearl II Diamond IV

Sapphire I Sapphire II

1st Preference Outlet Location City State

Cawangan Pilihan Pertama

2nd Preference Outlet Location City State

Cawangan Pilihan Kedua

3rd Preference Outlet Location City State

Cawangan Pilihan Ketiga

How do you become interested in NanoWash™ Outlet Program and why?

Bagaimana anda boleh berminat dengan Program Cawangan NanoWash™ dan kenapa?

Have you ever or currently owned a laundry business?

Pernahkan anda memiliki atau sedang menjalankan perniagaan dobi? Yes No
If yes please give details (address, contact no. & years of operation)
Jika ada sila beri penerangan (alamat, no.perhubungan & tahun beroperasi)

Have you ever been involved in any litigation or settlement with respect to your previous business history?
Pernahkan anda terlibat di dalam isu mahkamah atau penyelesaian undang-undang berkaitan dengan sejarah perniagaan anda? Yes No
If yes please give details
Jika ada sila beri penerangan

What percent of the business will you own? Will you work in the business full time?
Berapa peratus anda memegang kepentingan didalam perniagaan ini? Adakah anda akan bekerja sepenuh masa didalam perniagaan ini? % Yes No
If no please explain
Jika tidak sila jelaskan

Who will be responsible for the day-to-day operations?

Siapa yang akan bertanggungjawab didalam operasi harian?

DECLARATION : OFFICE USE

The undersigned certifies that the information furnished in this Outlet Application is a true and
correct statement of my (our) financial condition on the date indicated. I (We) agree to notify you Application : Approved Not Approved
immediately in writing of any material change in said condition. I (we) also authorize Miresco
Integrated Sdn Bhd, its affiliates and their authorized suppliers to make whatever investigations
and inquiries they may consider necessary to obtain all relevant character/credit information,
records of criminal offenses and to release to prospective financing sources such financial and other
information concerning me (us) in its files as may be requested. Comment :

Company Stamp
Date Participant Sign/Company Stamp Authorised Officer

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