APPENDIX PK17/05 (5)
SUPPLIER REGISTRATION FORM
INSTRUCTIONS:
1) The completed and signed Supplier Registration Form with Integrity Pledge and the required supporting
documents must be delivered by hand or mail to Reception Counter of Pembangunan Sumber Manusia Berhad
(PSMB) and attention to Procurement Unit.
2) The completed Supplier Registration Form in the Microsoft Excel format (softcopy) must be emailed to
[email protected] /
[email protected] without protection for easy retrieval of
information for our system usage.
3) This registration does not guarantee vendors are automatically included in the tender/quotation exercise.
PART 1 : COMPANY GENERAL INFORMATION
1.1 Company Registered Name :
1.2 Company Registration No. :
1.3 Date of Incorporation :
1.4 Company Registered Address :
1.5 Office Telephone No. :
1.6 Office Fax No. :
1.7 Company Website :
1.8 Company Official Email :
1.9 Company Correspondence Address :
1.10 Type of Company : Please select
1.11 Business Nature : Please select
1.12 Name of Company Representative :
1.13 Designation :
1.14 Mobile Phone No. :
1.15 Email Address :
1.16 Company Registered With : (Please tick the appropriate box)
Kementerian Kewangan Malaysia (MOF)
Pusat Khidmat Kontraktor (PKK)
CIDB
Professional Bodies (Please specify)
PART 2 : BUSINESS CAPITAL/EQUITY INFORMATION
2.1 Company Status : Please select
2.2 Equity Content
2.2.1 Malaysian (%) :
2.2.2 Foreign (%) :
2.3 Capital Structure
2.3.1 Authorised (RM) :
2.3.2 Paid-Up (RM) :
2.3.3 Working (RM) :
2.4 Annual Income/Turnover (RM) :
PART 3 : BANKING INFORMATION
3.1 SST Registration No. :
3.2 Bank Name :
3.3 Bank Address :
3.4 Branch Code :
3.5 Bank Account No. :
3.6 Swift Code :
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APPENDIX PK17/05 (5)
PART 4 : BUSINESS ACTIVITY
4.1 Category of Supplies/Services/Works :
(Please refer to Appendix A)
PART 5 : CREDIT/PAYMENT TERM
Please specify credit/payment term offered to PEMBANGUNAN SUMBER MANUSIA BERHAD (PSMB) if
your company is successfuly registered as Approved Supplier List. (Please tick the appropriate box)
30 days from the date of receipt undisputed invoice & its relevant supporting document.
45 days from the date of receipt undisputed invoice & its relevant supporting document.
60 days from the date of receipt undisputed invoice & its relevant supporting document.
Others (Please specify)
PART 6 : DOCUMENTS CHECKLIST
Please ensure to tick below box for the mandatory and required supporting documents provided:
Completed and signed PSMB Supplier Registration Form (Incomplete form will be rejected)
Completed and signed Supplier/Tenderer Integrity Pledge - Appendix PK04/05(4)
Company’s Profile (Organization Chart, Services Offered, Past projects, Product Catalogue)
e-info SSM or Any relevant SSM documents
Copy of certificate and business license with MOF, PKK, CIDB and/or others
Latest bank statement
Latest audited financial statement / management account
PART 7 : DECLARATION AND CERTIFICATION OF INFORMATION
“I/we hereby declare that I/we have no affiliations or relationships with any person or involvement in any
organization or entity with any financial or non-financial interest, whether direct or indirect, with PSMB
and/or its employees, servants, agents and/or consultants, including without limitation, members of PSMB’s
Board of Directors or the Ministry of Human Resources.
I/we hereby declare that to the best of my/our knowledge, the information I/we have provided is true and
correct and I/we undertake to advise PSMB in writing in the event a conflict or potential conflict of interest
Signature
arises in the future, and to withhold participating in: any process in which I/we may be compromised, until
further
Name directions are received from PSMB. :
NRIC/ Passport No. :
Citizenship :
Designation :
Date :
Company Stamp :
PERSONAL DATA PROTECTION ACT 2010 NOTICE
By submitting this form you agree that your personal data and other information provided in this application,
including any additional information you may subsequently provide, may be collected, used, disclose and
processed by PSMB as a reference in future to communicate with you in accordance with Personal Data
Protection Act 2010 and our data protection policy. For further information on our data protection policy,
please log on to www.hrdf.com.my.
FOR USE OF PEMBANGUNAN SUMBER MANUSIA BERHAD ONLY
Application Received Date :
Status :
Processed by :
Approved by :
Supplier Registration No. :
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LAMPIRAN PK17/05(5)
APPENDIX A
APPENDIX A : PRODUCT & SERVICES CATEGORIES
A SUPPLIES
A1 Office Supplies & Administrative
1. Office Furniture and Fixtures
2. Office Machines & Accessories
3. General Electrical and Electronic Appliances
4. Stationary & Office Supplies
5. Simili Paper
6. Photocopier/Printers Equipment
7. Wrapping & Packaging Materials
8. Mailing Supplies
9. Signage & Accessories
10. Others
A2 Food & Beverages
1. Pantry Supplies (Wet/Dry/Cans/Bottles/Packs Groceries)
2. Catering
3. Others
A3 Sports, Recreation & Music
1. Sports Wear & Accessories
2. Souvenirs / Gifts
3. Musical Instruments & Accessories
4. Camping Equipment & Accessories And Outdoor Activities
5. Sports and Gym Equipment
6. Others
A4 Uniforms, Textiles & Leathers
1. Uniform, Shoes, Accessories and Tailoring
2. Textiles Based Supplies (Other Than Uniforms)
3. Leather Based Supplies
4. Others
A5 Fire, Safety & Security
1. Fire Control Systems & Protection and Equipment
2. CCTV and Other Security Surveillance Systems and Equipment
3. Safety & Protective Tools
4. Others
A6 Computer/Server Equipment and Components, Application Software & Services
1. Hardware (low end technology) – Supply all types of computer hardware Including PC, notebook, printer, document
scanner, peripherals & maintenance
2. Hardware (high end technology) – All types of server, mainframe, high end Printers, storage area network (SAN, NAS)
including maintenance
3. Software – Supply all computer software, operating system, database, off-the-Shelf packages including maintenance
4. Software/System development/Customization and maintenance including data entry, data processing
5. Networking – Supply product, infrastructure, services including maintenance (LAN/WAN/Internet/wireless/satellite)
6. Data Management – Provide services including Disaster
7. ICT security and firewall, Encryption, PKI, Anti-Virus
8. Multimedia – Products, services and maintenance (video conferencing, web cast, Graphic design, animation)
9. Hardware and Software leasing/renting
10. Others
A7 Communication/Telecommunication Devices and Accessories
1. Telephone, PBX System Equipment and Components
2. Radio and Wireless Telecommunication Equipment and Components
3. Voice Telco Service Provider
4. Call Center System
5. Others Communication/Telecommunication
6. Others
A8 Healthcare
1. First Aid Kit
2. Medical Supplies
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LAMPIRAN PK17/05(5)
APPENDIX A
3. AED & CPR Equipment
4. Others
B SERVICES
B1 Consultancy Physical Services
1. Engineering
2. Architecture, Planning & Surveying
3. Others
B2 Consultancy Non-Physical Services
1. Financial & Accounting Management
2. Audit & Tax Management
3. Human Resource Management
4. Organization Management
5. Quality Management
6. Training/Course/Seminar Management
7. Property & Real Estate Valuation
8. Legislation
9. Marketing & Research
10. Economic
11. Statistic
12. Others
B3 Non-Consultancy Services
B3.1 Repair & Maintenance Machines & Vehicles
1. Air-Conditioning (Window/Split)
2. Air-Conditioning (Commercials)
3. Office Machines
4. Fire Extinguisher & Bomba Equipment
5. Communication & Broadcasting Equipment
6. Electric Systems & Appliances
7. Security Control Equipment
8. Mechanization System (Elevator / Escalator etcl)
9. Pump/Plumbing & Component
10. Vehicles (Motorcycle/Car/Lorry)
B3.2 Rental & Management
1. Office / Business Space
2. Heavy Machinery/Vehicles/Machinery
3. Exhibition / Stage / Event Organizer
4. Car Parking Lot
5. P.A. System / Sound & Lights / Musical Instrument
6. Office Machines
B3.3 Control & Supervision
1. Building Insect/Pest/Anti-Termite Control
2. Security Guards
B3.4 Cleaning, Washing & Disposal Services
1. Building Cleaning (Interior and Exterior)
2. General Cleaning
3. Domestic & Industrial Waste
4. Sewerage Plant and Installation Treatments and Inspection
5. Vehicle and Heavy Machinery Washing and Cleaning
6. Special Purpose Cleaning Chemical Services and Supplies
B3.5 Area Beautification
1. Interior Design / Decoration
2. Building
3. Landscaping & Gardening
B3.6 Transportation
1. Shipping & Fowarding Agent
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LAMPIRAN PK17/05(5)
APPENDIX A
2. Packing & Courier Consignment
3. Travel Agent
4. Lorry Transportation
5. Passenger Transportation
B3.7 Event, Advertising & Promotional
1. Electronic Media Booking
2. Print Media Booking
3. Creative Services
4. Advertising & Broadcasting Agency
5. Branding & Communication Agency
6. Promotional Material & Merchandise
7. Event Management Services
8. Sponsorship Event
9. Entertainment Services
10. Videography, Photography & Audio Visual
11. Billboard
12. Others
B3.8 Printing & Publication
1. Public Relation
2. Publication Agency
3. Magazines / Journals / Books / Press Release
4. Brochures, Posters, Buntings and Banners
5. Corporate Books, Diary and Calendar
6. Name Cards, Labels, Stickers & Rubber Stamps
7. Forms and Receipts
8. Letterhead
9. Envelope
10. Publishing, Binding & Laminating
11. Controlled Items & Printing Supplies
12. Others
B3.9 Instructor / Speaker / Trainer
B3.10 Hotel and Training/Conference Facilities
B3.11 Tailoring
B3.12 Insurance
B3.14 Other Services
C WORKS
C1 Civil & Structure Services
C2 Mechanical & Electrical Services
C3 Plumbing & Sewerage
C4 Landscape & Gardening
C5 Building Services
C6 Interior Design
C7 Security System
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