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PU/UPS/1-V.

1/10(BI)

DECLARATION FORM FOR REGISTRATION OF COMPANY/CONSULTING FIRM WITH THE MINISTRY OF FINANCE MALAYSIA
Application Reference No Application Type : K-07092012-9555 : Renew Application

Declaration For Application To Register With The Ministry Of Finance Malaysia
1. I/We declare that submission of all information in this declaration form, application form and supporting documents is correct and valid. I/We hereby allow the Ministry of Finance to verify any information in this declaration form, application form and supporting documents with the company/consulting firm or any other third party. I/We agree that I/we am/are responsible to update any changes in the company's information if any, after registration within twenty-one (21) days from the date the changes occur. If I/we fail to do so, the Ministry of Finance Malaysia may cancel the registration or take other actions.

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I/We consent to the Ministry of Finance Malaysia representative to visit the company/consulting firm premises for the inspection/audit purposes and to verify the documents and related information. I/We declare that the company/consulting firm does not have Owners, Board of Directors/Directors, Managers and Employees in any company/consulting firm who have been registered with the Ministry of Finance in the same category/categories. I/We agree that only personnel authorized by the company/consulting firm and the names stated in the Company/Consulting Firm Registration Certificate are allowed to do any transaction in Government procurement on behalf of the company/consulting firm. I/We agree that the company/consulting firm after being newly registered is not allowed to make any changes to Equity Ownership and Board of Directors/Managers within six (6) months from the date of registration. I/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/parties for the purpose of improving the Government delivery system. I/We understand that failure to comply with any of the above conditions, the Ministry of Finance Malaysia has the right to reject the company/consulting firm's application. If the application is rejected, the documents submitted will be returned by post/courier except when requested by the company/consulting firms, the documents will be held temporarily for fourteen (14) days from the date of rejection. The document will return by mail if they remain unclaimed within this period.

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I/We understand that whatever documents submitted for registration will become the Government property for any applications that have been approved or rejected after the visit/audit. I/We agree to give permission to the Ministry of Finance Malaysia to cancel the registration and delete all records/data automatically from the ePerolehan system if I/we do not renew the company/consulting firm registration within one (1) year from the expiry date of specify registration. I/We may make a new application if still interested to register with the Ministry of Finance Malaysia after the period.

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I/We understand that the Government and the Ministry of Finance Malaysia is not responsible for any loss(es) or damage(s) on the company /consulting firm that have been registered with the Ministry of Finance Malaysia and/or use any information obtained from this website: www.eperolehan.gov.my. I/We also agree that the approval of registration will not in any way bind the Government to offer any Government procurement to the company/consulting firm. I/We understand that any act or attempt to corruptly offer or give, solicit or receive any gratification to and from any person relating to Government procurement is a criminal offence under the Malaysian Anti-Corruption Commission Act 2009 [Act 694]. If any individual attempts to seek bribe from the company/consulting firm as an offer/or gratification pertaining to Government procurement, I/we will immediately lodge a report at the nearest office of the Malaysian Anti-Corruption Commission (MACC) or police station.

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Signature Applicant's Name* NRIC/Passport No. Designation Name of Company/Consulting Firm Date

: : : : Official Seal Of Company/Consulting Firm

: NORANI BTE NADZIR : 18/09/2012

* Notes: To be signed by Owner/Director/Manager of the company/consulting firm which have been declared in the ePerolehan System only.