MALAYSIAN TECHNOLOGY DEVELOPMENT CORPORATION SDN BHD TENANT APPLICATION FORM MTDC TECHNOLOGY CENTRES ( Tick accordingly) UPM-MTDC Technology Centre, Serdang, Selangor (MSC Malaysia Cybercentre) UKM-MTDC Technology Centre, Bangi, Selangor UTM-MTDC Technology Centre, Skudai, Johor FRIM-MTDC Technology Centre, Kepong, Selangor UiTM-MTDC Technopreneur Centre, Shah Alam, Selangor SECTION A Particulars of Company Company Name (Registration No.) GST No. Correspondence Address Website Date of Incorporation Date of Operation 1. Contact Person: Particular Top Management (CEO/MD/Director) Admin Finance Name Designation Telephone Mobile No. Fax Email Page 1 of 8
2. Staff strength: CATEGORY OF EMPLOYEES Management staff Technical/R&D staff HR/Admin/Support Staff Internship program staff (Please specify name of institute) Number of employees to be based at the Technology Centre NUMBER OF PEOPLE CURRENT YEAR ( ) Education status breakdown (number of employees) PH.D : MASTERS : BACHELORS : DIPLOMA : OTHERS : * Please attach additional pages if necessary 3. Company Background: Technology Cluster ICT Biotechnology Life Sciences Advance Engineering Nano Technology Innovative Industrial Design Others, please specify Summarise the nature of business in a paragraph Company Certification Status (tick if applicable) Other Related Company (Branches, Subsidiaries, Group etc) Bio Nexus (MBC) MSC (MDeC) TERAS (Teraju) Pioneer (MIDA) Others: Please specify * Please provide a copy of certificate Page 2 of 8
SECTION B Capital Structures 1. Authorised Capital RM 2. Paid Up Capital RM 3. Structure of Shareholding Nationality No. of Shares % Malaysian Foreign (Specify Country) Total 4. Shareholders No Shareholder s Name Nationality No. of Shares % 1. 2. 3. 4. 5. 5. Parent Company (if applicable) : 6. Board of Directors No Name Nationality Address 1. 2. 3. 4. 5. 7. Financial Institutions No. Banker Account Number 1. 2. Page 3 of 8
SECTION C Business Activities 1. Summary of Current Core Activities. (Please attach product brochures, if any) 2. Development Plans for the next three years. 3. Collaborations with universities or research institutes. (Supporting documents, if any) University/Research Institute: Project Title: Collaborator Name: Project Milestone: Supporting Document: Copy of MOU/ MOA/Letter SECTION D Business Income and Customers Annual Sales Turnover Current Year Next Projection RM RM 1. Other source of financing / funding MTDC Others Type RM Type RM CRDF Loan TAF Shareholder advance BSF Venture Capital BGF Others: Total Total Page 4 of 8
2. Main Customers Please specify current projects or activities. 1. 2. 3. SECTION E Required Office Space Details of Office Space Requirement 1. Type of Space Required Technology Garage Enterprise Server Farm Lab 2. Purpose of having space Office Showroom Production R & D Others (Please specify) 3. Block Name/ Unit No. 4. Size of Space (sq ft) 5. Expected Move In Date SECTION F MTDC Services 1. Which of the service(s) will you need to assist your management? Business Development Fund Raising Technology Licensing Student Internship Entrepreneurship Program/ Training Recruitment from University Graduate Scientific Equipment Facility (Please specify ) Other Assistance or Training Course (Please specify ) Page 5 of 8
Declaration Form: MTDC-F13 hereby declare as follows:- (i) (ii) (iii) (iv) (v) all information as provided in this form is true, complete and accurate; all documents submitted and provided with this form is true, complete and accurate; there are no winding-up proceedings against or no receiving order has been made against the Company; is not in default under any agreement to which it is a party or by which it may be bound and no litigation, arbitration, administrative or legal proceedings suit or action as the case may be, are pending threaten or has been instituted against which might materially affect its solvency; and that this declaration is made in full knowledge and awareness of MTDC reliance on this declaration as a basis to consider application for tenancy at MTDC Technology Centres. Date Name Designation Signature Company Stamp Prepared by Name Designation Contact No. Signature Page 6 of 8
*Checklist for items to be submitted (Sdn Bhd/ Berhad/ Limited Liabilities Partnership (LLP)/ Enterprise Form: MTDC-F13 Tenant Application Form (fully completed) Company Profile (includes Organisation Chart & Business Card) & Product Brochure Latest 3-months Bank Statement An original copy of the Latest Companies Commission of Malaysia (CCM) corporate information print-out (https://www.ssm-einfo.my/index.php?id=login) Complete M&A Forms 9, 24, 49 (any related registration/ latest transfer forms & 32A (if applicable) (for Sdn Bhd/ Berhad only). Partnership Agreement (for Limited Liabilities Partnership (LLP) only). Form D (for Enterprise only). Latest Audited Account (if applicable). *Checklist for items to be submitted (Government Agency/ Faculty/ Institute) Tenant Application Form ((fully completed) exceptional for Section B & D) Organisation Profile (includes Organisation Chart & Business Card) & Product Brochure (if applicable) Authorisation Letter for Payment *The management reserves the right to reject or return any application if information provided is incomplete. Please send the completed form and all documents to the address listed below: MALAYSIAN TECHNOLOGY DEVELOPMENT CORPORATION SDN BHD (MTDC) Management Office Technology Centre Management Unit, Nurturing Department Level 1, Block B UPM-MTDC Technology Centre III Universiti Putra Malaysia 43400 Serdang Selangor Darul Ehsan TEL : 03-8941 4100 FAX : 03-8941 4200 Website: www.mtdc.com.my Page 7 of 8
For office use only Form: MTDC-F13 Enquiry Date : Site visit Date : Interview Date : Application submission Date : Last document received Date : SC / CR Date : SC / CR No. : Number of days processed : Processed by : Reviewed by : Referral: Walk-in Family & Friend MTDC Website Publication/ Media Staff Property Agent Associated Company Subsidiary Company Tenant Host University/RI s Government Agency Others Officer Recommendation: Approve Reject Return KIV Comment: Page 8 of 8