SURUHANJAYA KOMUNIKASI DAN MULTIMEDIA MALAYSIA BORANG PERMOHONAN LESEN PERKHIDMATAN BUKAN SEJAGAT NON-UNIVERSAL SERVICE LICENCE APPLICATION FORM A. KELAS LESEN DIPOHON /LICENCE CLASS APPLIED A1 Kelas lesen dipohon Applied licence class A2 Kawasan perkhidmatan (untuk Kelas C sahaja) Service area (only for Class C ) B. BUTIRAN PEMOHON / APPLICANT PARTICULARS B1 Nama syarikat Company’s name B2 No. pendaftaran perniagaan Business registration no. Kelas A Class A Kelas B Class B Kelas C Class C Tandakan ‘X’ (satu sahaja) Mark ‘X’ (only one) Tarikh ditubuhkan Incorporation date B3 - - (Seperti Borang 9 atau Borang 13 jika berkenaan) (As per Form 9 or Form 13 if relevant) B4 Alamat berdaftar (Seperti Borang 44) Registered address (As per Form 44) Poskod Postcode Bandar Town Negeri State No. telefon Telephone no. B5 No. faks Fax no. Alamat premis perniagaan Business premise address Poskod Postcode Bandar Town Negeri State No. telefon Telephone no. B6 Laman sesawang Website B7 Modal dibenarkan Issued capital No. faks Fax no. RM B8 1|5 Modal berbayar Paid-up capital RM Borang Permohonan Lesen Perkhidmatan Bukan Sejagat / Non-Universal Service Licence Application Form B9 Maklumat pemegang saham (5 pemegang saham utama sahaja jika syarikat adalah syarikat awam berhad) Particulars of shareholders (5 substantial shareholders only if the company is a public limited company) No. No. B10 No. MyKad MyKad No. / No. Pasport Passport No. / No. Pendaftaran Perniagaan Business Registration No. Bumiputera Bumiputera (B)/ Bukan Bumiputera Non-Bumiputera (BB)/ Asing Foreign (A) % Pegangan Saham % of Shares Allotted Maklumat pengarah Particulars of directors No. No. B11 Nama / Institusi / Syarikat Name / Institution / Company Nama Name No. MyKad / No. Pasport MyKad No. / Passport No. Warganegara Nationality Jawatan Position No. telefon & emel Telephone no. & email Maklumat pengurusan tertinggi dan kanan syarikat Company’s highest and senior management details No. No. Nama Name 2|5 Borang Permohonan Lesen Perkhidmatan Bukan Sejagat / Non-Universal Service Licence Application Form C. LAPORAN KEWANGAN / FINANCIAL REPORT 3|5 Borang Permohonan Lesen Perkhidmatan Bukan Sejagat / Non-Universal Service Licence Application Form C1 Kedudukan kewangan syarikat untuk 3 tahun terkini seperti laporan tahunan kewangan yang diaudit Company’s financial standings for latest 3 years as per audited annual financial report 201… 201… 201… a. Pendapatan Revenue RM RM RM b. Untung / Rugi Sebelum Cukai Profit / Lost Before Tax RM RM RM D. MAKLUMAT OPERASI / OPERATIONS DETAILS D1 Jenis perkhidmatan kurier yang sedang/akan diberikan - tandakan ‘X’ Types of courier services that are/will be provided - mark ‘X’ Antarabangsa (keluar) International (outbound) Antarabangsa (masuk) International (inbound) D2 Lain-lain perkhidmatan termasuk aktiviti perniagaan sekarang (Contoh: serahan pejabat, bilik mel, logistik dan penggudangan) Other services including current business activities (E.g.: despatch, mail room, logistics and warehousing) D3 Tenaga kerja, akses, kenderaan dan penghantaran untuk 3 tahun terkini Work force, access, vehicles and deliveries for latest 3 years a. Jumlah pekerja No. of employees b. Jumlah akses / outlet No. of access / outlet Antara bandar Inter-city 201… Dalam bandar Intra-city 201… 201… Cawangan Branches Agen Agents Lampirkan butiran cawangan dan agen berserta alamat / Attach details of branches and agents including addresses c. Jumlah kenderaan No. of vehicles Motorsikal Motorcycles Van/Kereta Vans/Cars Lori Lorries d. Jumlah penghantaran setahun (permohonan pembaharuan sahaja) No. of deliveries per year (renewal application only) Surat Letters Bungkusan Parcels D4 Sistem jejak & kesan Track & trace system D5 Lain-lain teknologi/ICT jika ada Other technologies/ICT if available D6 Pasaran utama/sasaran perkhidmatan kurier Courier services major/ target market E. Atas talian Online Manual Manual a. b. Tandakan ‘X’ Mark ‘X’ c. (Contoh: e-dagang, perbankan, perkilangan atau komersil) (E.g.: e-commerce, banking, manufacturing or commercial) PELAN PERNIAGAAN (PERMOHONAN BAHARU) / BUSINESS PLAN (NEW APPLICATION) 4|5 Borang Permohonan Lesen Perkhidmatan Bukan Sejagat / Non-Universal Service Licence Application Form E1 Sumber kewangan untuk beroperasi dan jumlah pelaburan Sources of funds to operate and total investment E2 Unjuran

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