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MTDC Office
Version D.01.10

DISBURSEMENT REQUEST FORM FOR MTDC


(please leave this
GRANT DISBURSEMENT NO. ( ) column blank)

A. COMPANY DETAILS (√) Remarks

Name of Company : NOX DIVIUM SDN BHD

Date of Expiry of Agreement : 31 August 2018 Amount Approved (RM):695 361.45

Amount Disbursed To Date (RM):0

Amount Requested for This Disbursement (RM): 85586.86

B. DETAILS OF PROGRESS REPORT & WORKSHOP ATTENDED (√) Remarks

Date of Last Workshop Attended

Number of Progress Report Submitted to Date


7
(Submitted / Total Progress Reports)

All Timely  All Delayed  Mostly Timely x


Mostly Delayed 

C. CHECKLIST OF DOCUMENTS SUBMITTED FOR DISBURSEMENT (√) Remarks

i. Proof of Financing (applicable for first claim


X Yes  No  N/A
only)

ii. Collaboration Agreement (if applicable)  Yes  No X N/A

iii. Disbursement Table (Hardcopy & Softcopy) X Yes  No  N/A

iv. Documents as Proof of Payment X Yes  No  N/A

v. Corporate Information of Supplier(s)  Yes  No X N/A

a. If supplier company is incorporated in


Malaysia:-

(i) the latest corporate information obtained


from Companies Commission of Malaysia
(CCM) i.e one (1) original copy of CCM
print-out and; and

(ii) such other documents as may be


requested from MTDC.

1 Request for MTDC Grant Disbursement


b. If supplier is a foreign company, the latest
corporate information documentation
(original copy) obtained from its respective
local authority of country of origin.
If the said supplier has place of business or
carry on business in Malaysia:-

(i) the latest corporate information obtained


from Companies Commission of Malaysia
(CCM) i.e one (1) original copy of CCM
print-out; and

(ii) such other documents as may be


requested from MTDC.

vi. Any Other Documents as Stipulated under


the ‘Conditions for Disbursement’ in the Offer
Letter/Fund Agreement  Yes  No X N/A
Please specify :
__________________________

vii. All Documents (Item ii, iv and v) Must be


Certified True Copy by Company Secretary X Yes  No  N/A
or Auditor

D. DETAILS OF BENEFICIARY FOR DISBURSEMENT PURPOSE (√) Remarks

For Payments in Malaysia


(Please add as necessary if the number of beneficiary is more than one)

Payment to be Made to (Name of Beneficiary) NOX DIVIUM SDN BHD

Amount to be Paid (RM) 85 586.86

For International Payments


(Please add as necessary if the number of beneficiary is more than one)

Payment to be Made to (Name of Beneficiary)

Amount to be Paid (RM)

Bank Address

Account
Swift Code
Number

2 Request for MTDC Grant Disbursement


E. DECLARATION

(Nox Divium Sdn Bhd) hereby declare as follows:-

(i) all information as provided in this form is true, complete and accurate;

(ii) all documents submitted and provided with this form is true, complete and accurate;

(iii) that there are no common directors and/or shareholders between (Nox Divium Sdn Bhd) and the beneficiary/(ies)
as stated under Section D; and

(iv) that this declaration is made in full knowledge and awareness of MTDC’s reliance on this declaration as a basis to
disburse the grant monies to the beneficiary/ (ies) as stated under Section D and in the manner as specified in this
form.

Name: Signature:
Designation:
Date: Company Stamp:

F. DETAILS OF PERSON FOR MTDC TO CONTACT REGARDING DISBURSEMENT

Name of
Contact DR DHAYANAND Email Address dhaya777@gmail.com
Person

Office Number Mobile Number 012 298 3757 Fax Number

Mailing
1-1, Suasana Bangsar, 1, Jalan Kaloi, 59100 KL
Address

FOR MTDC OFFICE USE ONLY


A. Officer Assigned for Processing

B. Recommendation (√ whichever applicable)

i. To Proceed with Processing

ii. Pending Further Information


(Attach Copy of Letter/Email Listing Down the Information Required)

iii. To Return the Claim


Reason ..........................................................................................................

C. Decision

Agree / Do not Agree with the Recommendation (Please circle whichever applicable)

Name of Head of Department : ........................................... (Signature)

3 Request for MTDC Grant Disbursement


(Date)

Comments: ........................................................................................................................

4 Request for MTDC Grant Disbursement