Asian Integrated Medical Sdn. Bhd.

Document No. AIM-F28

Dealership Application Form Revision No. 0

Effective Date 2 April 2018

 
BUSINESS  CONTACT  INFORMATION  
Business  Name:    
Business  Registration  No.:    
GST  Tax  Number:    
Business  Address:    
 
 
Telephone  Number:    
Fax  Number:    
Person/s  to  contact:    
Email  Address:    
Mobile  Number:    
 

Type  of  Business:     Sole  Proprietor     Partnership     Sdn.  Bhd.     Bhd.     Individual  
Nature  of  business:     Distributor     Pharmacy     Trading     Dealer     Agency  
Date  Incorporated:    
(Please  tick  appropriate  box)  

Name  of  Directors:    

Paid  up  Capital  (RM):    
Annual  Turnover  (RM):    
Name  of  Bank  Used:    
Bank  Account  Name:    
Bank  Account  Number:    
Email  Address  (Account):    
Signature  and  Company    
Stamp:  
Name:  
Date  

Note:  

Please  e-­‐mail  the  following  documents  to  sales@ielder.my  with  subject  titled:  “Dealership  Application”.  

i. For  individuals;  Please  attach  an  I.C.  of  key  person.    

ii. For  Sdn.  Bhd.;  Please  attach  Form  9,  Form  24,  Form  49  and  I.C.  of  key  person.  
iii. For  Sole  proprietor;  Please  attach  Form  D,  I.C.  of  key  person.  
FOR  ACCOUNT  USE  ONLY:  

Debtor  Account  No.:    

Authorized  Signature:    

Name:  
Date: