Name as per NRIC/Passport
(Nama seperti tertera di No. KP/Passport)

NRIC
(No. Kad Pengenalan)

Home Address
(Alamat Rumah)

Mobile No.
(No. Telefon)

Home No.
(No. Telefon Rumah)

Date of Birth
(Tarikh Lahir)

Email
(E-mel)

Nationality
(Warga Negara)
MalaysiaOthers

Marital Status
(Status Perkahwinan)
SingleMarriedWidowedSeparatedDivorced

Race
(Bangsa)

Gender
(Jantina)
Male (Lelaki)Female (Perempuan)

Spouse Details (If applicable)
Butiran Pasangan (Jika Berkenaan)

Name as per NRIC/Passport
(Nama seperti tertera di No. KP/Passport)

NRIC
(No. Kad Pengenalan)

Home Address
(Alamat Rumah)

Mobile No.
(No. Telefon)

Email
(E-mel)

Nationality
(Warga Negara)
MalaysiaOthers
Race
(Bangsa)


Licensee Plans (Pelan Pemegang Lesen)

Will the licensee be owned by yourself, family members or company?
(Adakah pemegang lesen akan dimiliki sendiri, ahli keluarga atau syarikat?)

Location of Interest
(Lokasi Berminat)




Town
(Bandar)

State
(Negeri)

** minimum size of premis - 1,200 sq ft
Rental Range(RM):
(Julat Sewaan(RM))

Amount of Capital Available For This Business RM470,000 and Above?
(Jumlah Modal yang Tersedia untuk Perniagaan Ini adalah RM470,000 dan Ke Atas?)
YesNo

Business and Experience Record
(Rekod Perniagaan dan Pengalaman)

Current Employer/Business Owned
(Majikan Semasa/Milik Perniagaan)

Start Date
(Tarikh Mula)

End Date
(Tarikh Akhir)

Position
(Jawatan)

Annual Income
(Pendapatan Tahunan)

Previous Employer/Other Business Owned
(Majikan Terdahulu/Milik Perniagaan Lain)

Please Attach Candidate Photo
(Muat Naik Gambar Calon)

I hereby confirm that the information stated above is true and accurate. I understand that false information may be grounds for not considering me or immediate termination of licensee at any point in the future if I am appointed.