Reseller Registration Form

Company Information

Company Name : Enter text

Phone Number : Enter text

Email : Enter text

Website : Enter text
Mailing Address : Enter text

SSM : Enter text

Registered date : Enter text

Company Type : Enter text

Berhad Sdn. Bhd. Partnership Individual Others:

…………..

Primary Contact Information

This person will be the one responsible for receiving bid invitations,
information & updates on behalf of your company.

Full Name : Enter text

Title : Enter text

Enter text
Email :
Enter text
Number :

Coverage Area

Klang Valley (Selangor, Kuala Lumpur & Putrajaya)

Northern Southern East Coast

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 Sabah Sarawak Others:…………..

Government /Private Certifications

Please select all applicable certifications:

Ministry of Finance (MOF)

Enter text
Certification Number :
Expiration Date : Enter text

Other Certification (Optional)

Enter text
Certification Number :
Expiration Date : Enter text

Type of Work, Service or Trade

Yearly Project Size (Average):

RM0 - RM500,000
RM500,000 - RM1 Million
RM1 Million- RM5 Million
RM5 Million +

Please tick the industries your serve :

Education Manufacturing
Transportation Oil & Gas Industry
Local Municipals Health care
Central Government Finance/Banking
State Government Other (please specify)
…………………….

Please email the form to rsp-sales@qinetics.net or the person in

contact to complete the registration. Thank you.

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