PROGRAM IMUNISASI INDUSTRI COVID-19 KERJASAMA AWAM SWASTA

(FOR COMMON SITE PPV APPLICATION)

COMPANY BUSINESS
NO. COMPANY/ ORGANISATION/ AGENCY REGISTRATION ADDRESS POSTCODE STATE ACTIVITY
NO.

1 Subsidiary A Location A
2 Subsidiary B Location B
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

Note:
1. For companies which has more than one (1) company interested in registering concurrently.
2. Location and state of the company will need to be specified to allow MITI to assign the nearest common-site PPV.
 FORM 1

MA AWAM SWASTA (PIKAS) PUSAT PEMBERIAN VAKSIN (PPV)

ON SITE PPV APPLICATION)

CONTACT PERSON DETAILS

TOTAL NUMBER OF POSITIVE MANUFACTURING
EMPLOYEES CASES (ACTIVE CASES LICENSE / MIDA
PHONE NO./ (registered for AT THE TIME OF EXEMPTION LETTER/ PBT ANNEX
NAME EMAIL vaccination) APPLICATION) LICENSE REGISTRATION
Annex 1
Annex 2
To be filled by the companies

Company Location: ………………………………………………………………………. (e.g. Industrial Estate/ Industrial area/ industrial zone)

Details of Company: (to be completed by company for their local and foreign employees already registered for COVID-19 Vaccinati
Company Name: ……………………………………………………………………………..
Company Registration No.: …………………………………………………………….
Company Address : ……………………………………………………………………………..
…………………………………………………………………………………
Postcode : ……………………………………………………………………………………
Tel No. : ………………………………………..
Contact person 1 Name : …………...……………………………
Designation:…………………………………..
H/P No.: ……………………………………….
Email Address:……………………………….

Contact person 2 Name:…………………………………………..

Designation: ……………………………………
H/P No.:………………………………………….
Email address: ………………………………….
Total head count registered under COVID-19 Vaccination Programme : ………………………….

No. Name No. I/C or Passport No. Employee ID Company Name/

Kementerian

DISCLAIMER

We hereby confirm that the information provided herein is accurate, correct and complete and that the documents submitted along with this application form are gen
(MITI) in writing (at vaccine4industry@miti.gov.my) of any changes to the information already provided and update the information on this form whenever requested

We hereby declare that, in the event of our information in this form will be required to be shared with other Ministries and/or agencies for the purpose of the Immuni
information without the need for MITI to notify us or to seek our additional consent.
 ANNEX 1

ea/ industrial zone)

tered for COVID-19 Vaccination Programme)

Gender
MySejahtera ID Phone No. Age Kindly indicate - 1 (for male)
2 (for female)

g with this application form are genuine. We undertake to inform the Ministry of International Trade and Industry
n on this form whenever requested to do so by the MITI.

ncies for the purpose of the Immunisation Programme, we explicitly agree to MITI’s full compliance to provide such
To be filled by the companies

Company Location: ………………………………………………………………………. (e.g. Industrial Estate/

Details of Company: (to be completed by company for their local and foreign employees
Company Name: ……………………………………………………………………………..
Company Registration No.: …………………………………………………………….
Company Address : ……………………………………………………………………………..
…………………………………………………………………………………
Postcode : ……………………………………………………………………………………
Tel No.: ………………………………………..
Contact person 1 Name : …………...……………………………
Designation:…………………………………..
H/P No.: ……………………………………….
Email Address:……………………………….

Contact person 2 Name:…………………………………………..

Designation: ……………………………………
H/P No.:………………………………………….
Email address: ………………………………….
Total head count registered under COVID-19 Vaccination Programme : ………………………….

No. Name No. I/C or Passport No. Employee ID

DISCLAIMER

We hereby confirm that the information provided herein is correct and complete and the documents submitted alo
International Trade and Industry (MITI) in writing (at vaccine4industry@miti.gov.my) of any changes to the informa
do so by MITI.

We hereby declare that, in the event of our information in this form will be required to be shared with other Minist
to MITI’s full compliance to provide such information without the need for MITI to notify us or seek our additional c
 ANNEX 2

g. Industrial Estate/ Industrial area/ industrial zone)

oreign employees already registered for COVID-19 Vaccination Programme)

………………..
……………………
………………………

………………………….

Company Name/
Kementerian MySejahtera ID Phone No. Age
ocuments submitted along with this application form are genuine. We undertake to inform the Ministry of
changes to the information already provided and to update the information on this form whenever requested to

hared with other Ministries and/or agencies for the purpose of the Immunisation Programme, we explicitly agree
or seek our additional consent.
 Gender
Kindly indicate - 1 (for male)
2 (for female)