BORANG/FORM AJL-1

PERATURAN-PERATURAN JUALAN LANGSUNG 1993(DIRECT SALES REGULATIONS 1993)

Peraturan 3(Regulation 3)

PERMOHONAN UNTUK MENDAPATKAN LESEN(APPLICATION FOR A LICENCE)

Pengawal Jualan Langsung, Kementerian Perdagangan Dalam Negeri Dan Hal Ehwal Pengguna, Bahagian Perdagangan Dalam Negeri, Aras 4, Lot 2G3, Presint 2, Pusat Pentadbiran Kerajaan Persekutuan, 62623 PUTRAJAYA.

Tuan/(Sir),

Saya/Kami, …………………………………………………………………………………….(I/We Nama Syarikat (Name of Company)

ingin memohon mendapatkan lesen untuk menjalankan perniagaan jualan langsung.(wish to apply for a licence to carry on a direct sales business.)

NOTA:(NOTE):

Jika ruang yang disediakan tidak mencukupi untuk memberi perincian, sila gunakan lampiran. Setiap lampiran mestilah ditandatangani oleh pemohon.(If the space provided is not sufficient to provide details, please attach annexure(s). Each annexure must be signed by the applicant.)

1. BUTIR-BUTIR SYARIKAT (PARTICULARS OF COMPANY)

(a) Alamat Berdaftar: (Registered Address):

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No. Telefon: ……………………………………………………(Telephone No.):

No. Telefaks: …………………………………………………..(Telefax No):

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(b) Alamat Surat-menyurat: (Correspondence Address):

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No. Telefon: ……………………………………………………(Telephone No.):

No. Telefaks: …………………………………………………..(Telefax No):

(c) No. Pendaftaran Syarikat: …………………………………………………….. (Company’s Registration No.):

(d) Tarikh Pendaftaran: …………………………………………………………….. (Registration Date);

(e) No. Lesen Perniagaan (Dewan Bandaraya/Majlis Perbandaran): (Business Licence No. (City Hall/Municipality):

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(f) No. Cukai Pendapatan Syarikat: ……………………………………………...

(g) Jenis Perniagaan Yang Didaftarkan: (Company’s Income Tax No.):

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(h) Perniagaan Utama dan Bidang Operasi: (Principal Business and Field of Operations):

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(i) Alamat Tempat Perniagaan (termasuk semua cawangan dan pembekal): (Address of Business Premise (including all branches and stockists):

Alamat(Address)

No. Telefon(Telephone No.)

No. Telefaks(Telefaks No.)

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2. STRUKTUR MODAL (CAPITAL STRUCTURE)

(a) Modal (i) Dibenarkan: RM …………………………..(Capital) (Authorised):

(ii) Berbayar: RM …………………………..(Paid-up):

(iii) Modal Kerja:RM …………………………..(Working Capital):

(b) Kemudahan Kewangan(Financial Facilities)

Jenis Sumber Institusi Amaun (RM)(Type of Sources) (Institution) (Amount RM))

(i) ……………………… …………………………………. ……………………….

(ii) ……………………… …………………………………. ……………………….

(iii)…………………… …………………………………. ……………………….

(c) Akaun Syarikat(Company’s Accounts)

Nama Bank Alamat No. Akaun(Name of Bank) (Address) (Account No.)

(i) ……………………… …………………………………. ……………………….

(ii) ……………………… …………………………………. ……………………….

(d) Penandatangan Cek(Signatories of Cheque)

(i) ………………………

(ii) ………………………

(iii) ………………………

(e) Penyertaan Ekuiti/Modal Berbayar(Equity/Paid-up Capital Participation)

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(i) Bumiputera

(ii) Bukan Bumiputera(Non-Bumiputera)

(iii) Bukan Warganegara Malaysia(Not Malaysian

Citizen)

RM ……………………….

RM ....…………………….

RM ....…………………….

3. BUTIR-BUTIR PENGARAH DAN PEMEGANG SAHAM (PARTICULARS OF DIRECTORS AND SHAREHOLDERS)

(a) Pengarah Dan Saham Yang Dipegang (Directors And Their Shareholdings)

Nama Dan Alamat No. KP/No. Pasport WarganegaraSaham(Shares)(NRIC No.I Passport(Name And Address) (Citizenship) Jumlah

No.) %(Total)

(b) Pemegang Saham

(Shareholders)

Nama Dan Alamat No. KP/No. Pasport WarganegaraSaham(Shares)(NRIC No.I Passport(Name And Address) (Citizenship) Jumlah

No.) %(Total)

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4. BUTIR-BUTIR PENGURUSAN(PARTICULARS OF MANAGEMENT)

(a) Struktur Pekerjaan Sekarang

(Present Employment Structure)

Kategori KerjaBukan

Asing JumlahBumiputera Bumiputera(Job Category) (Foreign) (Total)(Non-Bumiputera)

(a) Pengurusan(Management)

(i) Profesional(Professional)

(ii) Pentadbiran(Administration)

(b) Eksekutif(Executive)

(i) Teknikal(Technical)

(ii) Pentadbiran(Administration)

(c) Pekerja Mahir(Skilled Wokers)

(d) Perkeranian(Clerical)

(e) Pekerja Am/Lain-Lain(General Worker/Others)

Jumlah (Total)

(b) Kakitangan Pengurusan(Management Staff)

Nama Jawatan Warganegara No. KP/(Name) (Position) (Citizenship) No. Pasport

(NRIC No. IPassport No.)

(i) ................................. ....................... ...............................................................................(ii) ........................... ....................... ..........................

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.....................................................(iii) ....................... ..............................................................................(iv) ....................... ..............................................................................(v) ....................... ...............................................................................(vi) ....................... ...............................................................................(vii) ....................... .............................................................................(viii) ....................... ..............................................................................(ix) ....................... ...............................................................................(x) ....................... ................................................................................

(c) Carta Organisasi(Organization Chart)

5. BUTIR-BUTIR PERBADANAN BERKAITAN DALAM PERNIAGAAN JUALAN LANGSUNG (PARTICULARS OF RELATED CORPORATIONS IN DIRECT SALES BUSINESS)

Alamat Surat-Perniagaan

menyurat, No. No. Pendaftaran Tarikh Utama danNama Syarikat Telefaks dan No. Syarikat Bidang OperasiPendaftaranTelefon

(Name of (Company’s (Principal(Correspondence (Date ofCompany) Registration Business andAddress, Telefax Registration)

No.)Field of

and TelephoneOperations)Nos.)

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BaBagi setiap syarikat yang disenaraikan di atas, sila berikan butir-butir mengikut butiran 2a, 2b, 2c, 2d, 2e dan 3.

(F ( For every company listed above, please provide details in accordance with items2a,2b, 2c, 2d, 2e and 3).

6. BUTIR-BUTIR PERNIAGAAN (PARTICULARS OF BUSINESS)

(a) Jenis Barang/Perkhidmatan yang Dipasarkan (Type of Goods/Services Marketed)

Bahan Kosmetik Barang/Kelengkapan Sukan(Cosmetics) (Sport Goodsl Equipment)Vitamin/Makanan

Perkakas Elektrik RumahTambahan/Makanan (Household Electrical Goods)Kesihatan(Vitamin/FoodSupplements/Health Food)

Barang-barang Kemas, Alat Penapis AirJam Tangan dan Barang (Water Purifiers)Kemas Kostum(Jewellery, Watchers

and Costume Jewellery)Pakaian/Bahan Tenunan Pinggan Mangkuk dan(Clothings/ Woven Peralatan DapurMaterial) (Crockery and Household

Goods)Ensaiklopedia/Buku Skim Percutian(Encyclopaedia/Books) Pengongsian Masa

(Time-sharing

Vacation Schemes)Barang Permainan Lain-lain(Toys) (Others)

(Jika lain-lain, berikan perincian)(If others, provide details)

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(Sila sertakan brosur/katalog/buku/maklumat termasuk harga barang/perkhidmatan yang dipasrkan).(Attach brochures/catalogues/books/information including prices of

goods/services marketed).

(b) Skim Pemasaran dan Perdagangan (Marketing and Trading Scheme)

(0) Pemasaran barang/perkhidmatan dikendalikan secara: (The marketing of goods/services takes the form of):

Pemasaran Satu Tingkat (Single Level Marketing)

Pemasaran Berbilang Tingkat (Multi Level Marketing)

Jualan Pesanan Pos (Mail Order Sales)

Lain-lain (Others)

(i) Sila beri maklumat lengkap mengenai skim pemasaran dan perdagangan dan carta-carta yang menunjukkan komisen- komisen/bonus-bonus yang diberikan pada semua tingkat rancangan jualan. (Please provide complete information on marketing and trading schemes and charts showing commissions/bonuses given at all levels of the sales plan).

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(ii) Adakah syarikat tuan mengamalkan kod etika perniagaan) (Is your company practising any business code of ethics?)

Ya(Yes)

Jika “Ya”, sila kemukakan(If “Yes”, please submit)

Tidak(No)

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(c) Butir-butir Lanjut Mengenai Skim Pemasaran dan Perdagangan(Additional Information on marketing and Trading Scheme)

(i) Fee kemasukan untuk Ya Tidakmenjadi pengedar/ (Yes) (No)wakil jualan/ejen/peraih/ahli(Entrance fee to becomedistributor/salesrepresentative/agent/dealer/member)

Jika “Ya,” nyatakan jumlah RM(If “Yes”, state the amount)

Adakah ini termasuk kit perniagaan/jualan?(Does this include business/sales kit?)

Ya Tidak(Yes) (No)

Jika “Tidak”, berapakah bayaran bagi kit perniagaan/jualan?(If “No”, what is the fee for business/sales kit?)

RM

Jika “Ya”, nyatakan jumlah bagi kit perniagaan/jualan(If “Yes”, state the amount for the business/sales kit)

RM

(ii) Adakah komisen/bayaran diberikan untuk memperkenalkan pengedar/wakil jualan/ejen/peraih/ahli baru? (Are commissions/payment given for introducing new distributor/sales representative/agent/dealer/member?)

Ya Tidak(Yes) (No)

(iii) Nyatakan fee lain yang dikenakan untuk menjadi pengedar/wakil jualan/ejen/peraih/ahli: (State other fees to become a distributor/sales representative/agent/dealer/member):

Pembelian stok/inventori RM(Purchase of stock/inventory)

Fee latihan RM

(Training fee)

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Lain-lain fee(Other fees)

RM ............................

Beri maklumat terperinci mengenai bayaran lain(Provide information in detail on other payments)

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(d) Syarat-syarat lain yang dikenakan untuk menjadi pengedar/wakil jualan/ejen/peraih/ahli (Other conditions imposed to become a distributor/sales representative/ agent/dealer/member)

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7. LAIN-LAIN (OTHERS)

(0) Namakan Persatuan/Pertubuhan Berdaftar yang anda menjadi anggota di dalam dan luar negeri

(Name the Registered Associations/Organizations of which you are a member, both inside and outside the country)

Nama dan Alamat Kaitan/Hubungan(name and Address) (Association/Relationship)

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8. PERAKUAN

Saya/Kami dengan ini mengemukakan dokumen-dokumen yang berikut: (I/We hereby submit the following documents):

(0) Memorandum dan Perkara-Perkara Persatuan (yang ditentusahkan melalui akuan berkanun oleh seorang pengarah); (Memorandum and Articles of Association (verified by a statutory declaration made by a director));

(i) Sijil Perbadanan, Borang 8 atau 9 (mana-mana yang berkenaan), Peraturan- Peraturan Syarikat 1966; (Certificate of Incorporation, Form 8 or 9 (whichever is applicable), Companies);

(ii) Borang 24 dan 49, Peraturan-Peraturan Syarikat 1966, yang diperakui oleh Pendaftar Syarikat; (Form 24 and 49, Companies Regulations 1966, certified by the Registrar of Companies);

(iii) Borang Penyata Tahunan suatu Syarikat Yang Mempunyai Modal Syer (menurut seksyen 165, Akta Syarikat 1965); (Form of Annual Return of a Company Having a share Capital (pursuant to section 165, Companies Act 1965));

(iv) Kunci kira-kira teraudit dan akaun untukng rugi yang terbaru; (Latest audited balance sheet and profit and loss account);

(v) Skim Pemasaran dan Perdagangan Syarikat; (Company’s Marketing and Trading Scheme);

(vi) Carta organisasi syarikat beserta nama-nama kakitangan yang memegang jawatan-jawatan penting; (Company’s organization chart together with the names and positions of key personnel);

(vii) Penyata terbaru caruman syarikat yang dikeluarkan oleh Kumpulan Wang Simpanan Pekerja (KWSP); (Latest statement of company’s contribution issued by the Employees Provident Fund (EPF));

(viii) Salinan terperaku surat Perjanjian/Perlantikan dengan Syarikat Utama jika berkaitan; (Certified copies of Agreement/Appointment letter with Principal Company if applicable);

(ix) Brosur-brosur syarikat mengenai barang/perkhidmatan yang dipasarkan; (Company’s brochures on goods/services marketed);

(x) Kod etika perniagaan; (Business code of ethics);

(xi) Dokumen lain yang berkaitan dengan bidang perniagaan seperti pendaftaran dengan SIRIM, Biro Pengawalan Farmaseutikal Kebangsaan dan lain-lain.

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(Other documents relevant to the business such as registration with SIRIM,National Pharmaceutical Control Bureau, etc.).

9. PERISYTIHARAN(DECLARATION)

Saya/Kami dengan ini mengaku segala maklumat di dalam Borang ini dan mana-mana lampiran adalah benar dan tepat.Saya/Kami faham bahawa apa-apa pernyataan palsu yang dibuat di dalam Borang

ini hendaklah menjadi suatu kesalahan di bawah Akta.(I/We hereby declare that all information in this Form and any annexure(s) are true andaccurate. I/We understand that any false statements made in this Form shall be anoffence under the Act).

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Tandatangan Pemohon(Signature of Applicant)

Nama:(Name):

No. KP/No. Pasport:(NRIC No./Passport No.):

Jawatan dalam Syarikat:(Position in Company):

...................................Tarikh (Date)

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................................Meterai Syarikat

(Company’s Seal)

NOTA: Mengikut seksyen 5 Akta Jualan Langsung 1993 Pengawal boleh meminta apa-apa maklumat atau dokumen lain yang dinyatakan olehnya dan boleh meminta maklumat atau dokumen yang berbeza daripada pemohon yang berlainan, atau

pemohon daripada golongan, kategori atau perihal yang berlainan.

NOTE: According to section 5 of the Direct Sales Act 1993 the Controller may request for such other information or documents as may be specified by him, and may request different information or documents from different applicants, or different classes, categories or descriptions of applicants.

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