DISTRIBUTOR/DEALER APPLICATION FORM(Please use Capital Letters only)

Application Type (please tick) Distributor Dealer

Product Type (please tick) Prepaid Data Postpaid Reload Others

COMPANY DETAILS

1) Company Name

2) Status of Company

Berhad Sdn. Bhd.Proprietorship Partnership

3) Company/Business Registration No : :

4)a) Date of Registration/ Incorporation/:

Formation of Business

b) Date of Commencement of Business :

c) Income Tax No :

5) Address of the Registered Office/ Principal Place of Business:

City : Postcode :

State :

Telephone No. :

Fax No. : :

Website :

6) Name of Management Team and Contact Details (Please attach separate Sheet, if required).

Name IC No Designation Contact Number Email Address

ALTEL/SNM/F001

FINANCE AND OPERATION DETAILS (Parts 7 & 9 for Distributor only)

7) Business Turnover:

Activities 2011 2012From Trading Activities (Retail)From Trading Activities (Distributorship)TOTAL

(*Place attach certified true copy of the last two years Audited Financial Reports and latest management account.)

8) Bank Information

a) Bank Name : b) Branch : c) Account No. :

9) Current Telco Distribution List (tick all that applies)

Hotlink/Maxis AppleCelcom SamsungXPax SonyTune Talk MotorolaDigi HTCU Mobile NokiaOthers : ________________ Others : _______________

DOCUMENTS REQUIRED (compulsory, please tick)

Distributor and Dealer : Distributor only :

Form 9/13 Latest 2 years Audited Financial ReportForm 24 Latest Management AccountForm 49 Latest 3 month Bank StatementSSM RegistrationBusiness License

(*Kindly ensure all documents are stamped Certified True Copy)DECLARATION

I, IC No. declare and affirm that the above details are true and correct to the best of my knowledge.

Signature :Date :

RECOMMENDATION (For Dealer only)

Distributor Name : _____________________________Distributor Code : _____________________________Authorized Signature : _____________________________

FOR OFFICE USE

This application is : Code Generated :ApprovedRejected Distributor CodeKIV

Dealer Code

Applicant Company Stamp

Distributor Stamp

Signature and Stamp