KULIM (MALAYSIA) BERHAD
(Company No. 23370-V)
Kulim (Malaysia) Berhad
POSTAL ADDRESS: K. B. 705, ULU TIRAM ESTATE
80990 JOHOR BAHRU, JOHOR, MALAYSIA Tel. : +607-8611611 / +607-8633333
Website : www.kulim.com.my Fax. : +607-8611701 / +607-8631519
Attn : PROCUREMENT & CONTRACT DEPARTMENT
CONTRACTOR / SUPPLIER REGISTRATION FORM
Thank you very much for your interest in doing business with our Company. We can assure you of your
commitment to providing equal opportunity for all business enterprise to participate in our contracting
activities. Our utmost consideration in the best value for money for all our stakeholders. Kindly fill the
form as complete as possible.
If you have ready prepared company file, please enclosed it with this registration form.
If space provided is insufficient, please use a separate sheet of paper.
COMPANY BACKGROUND
1. Business Name : _____________________________________________________________
2. Type : Sole Proprietor / Partnership / Private Company / Public Company*
3. Major Business Address Activities / Services (your company specialized area first)
a) __________________________________________________________________________
b) __________________________________________________________________________
c) __________________________________________________________________________
d) __________________________________________________________________________
4. Business address : _____________________________________
_____________________________________
_____________________________________
_________________________________
5. Office Tel. No. : _____________________________________
6. GPS Coordinate : _____________ N , ___________ E
7. Contact Person : _____________________________________
8. Position : _____________________________________
9. Tel. No. : _____________________________________
10. Email : _____________________________________
Employee
Do you service use :
a. Own workers : Yes/ No
b. Contract workers : Yes/ No
For Registered Company Only
Registration No. : ________________________________________________________________
Year of registration : ________________________________________________________________
Registered Address : ________________________________________________________________
Registration No. : ________________________________________________________________
Paid-up Capital : ________________________________________________________________
DIRECTORS
Name I/C No. Position Citizenship % Shareholding
(Note : Please enclose the Form 49 of your company)
*Please underline whichever is applicable
For Self-proprietorship only
Owner’s Name : _____________________________________
House Address : _____________________________________
_____________________________________
_____________________________________
I/C No. : _____________________________________
Citizenship : _____________________________________
KEY PERSONNAL
Working Experience (years)
Highest
Name Position Age In current line of In employment
Qualification
work of the Company
1)
2)
3)
4)
5)
MACHINERY / VEHICLE / MAJOR EQUIPMENT (movable/immovable)
Year of
Description Make / Model Location
Purchase
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
(NOTE: Our representatives shall be required to visit your office / factory / workshop from time to time)
CERTIFICATION / LICENCES & PERMITS / REGISTRATION / ACCREDITATION
(Which are required to support your business activities e.g. Pressure Vessel license issued by JKKP, ISO
9000, MSPO, RSPO, MPOB, CIDB, EPF, SOCSO, etc)
Description Issuing Body / Authority Validity
*Please underline whichever is applicable
BANKERS
(Please enclose the Photostat copy of the latest bank statement and other bank facilities i.e. Overdraft,
Loan, etc)
Name of Bank Branch Contact Person Tel. No.
COMPANY ANNUAL TURNOVER
(Please state the previous 2-years annual turnover of your Company)
Amount in Word (Ringgit Malaysia) Amount in Number (RM)
JOB HISTORY / MAJOR CONTRACTS SECURED FOR THE LAST 5 YEARS
(Please state only the 10 biggest contracts in term of value with the latest one first)
Contact Description Contact Value Awarding Party / Contract Period
Company
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
CONFLICT OF INTEREST
• I/we, warrant and declare as at the date of this appointment/letter, that I/we have no personal or
business relationship whether direct or indirect with any of the employees, shareholders, agents,
servants of Kulim (Malaysia) Berhad. I/we shall promptly disclose and notified Kulim (Malaysia)
Berhad upon happening any of the above.
BANKRUPTCY
• I/we declare that there is no current or pending bankruptcy and/or winding up proceedings or action
have been commenced against the Company.
CRIMINAL RECORDS
• Neither the vendor nor any of its directors, officers, employees and agents has been convicted of
any offence involving bribery or corruption of fraud; nor to the best of the Vendor’s knowledge, is
any such person the subject of any investigation, inquiry or enforcement proceedings by any
governmental, administrative or regulatory body regarding any offence or alleged offence under
the applicable laws, statutes, regulations and codes relating to anti-bribery and corruption matters.
_________________________________________
Name & Company Director (or Equivalent):
IC / Password No:
Position:
Name of the Company:
Company Stamp:
