Ref No : DFD-SM-CF-LAF1/PGPP-10/2/2011-R5

Particulars of Guarantors/Partners/Proprietor
A. Name of Applicant Company/Firm*:
Date of Birth (dd/mm/yy):

Name of Guarantor/Partner/Proprietor

Residential Address:

Citizenship: Identity Card(new) & International Passport No.:

Telephone No.

Home: ______________________________ Mobile: ______________________________

(Please attach photocopy)

B.

PROFESSIONAL/ACADEMIC QUALIFICATIONS:
Professional/Academic Qualifications Institution Attended Year of Graduation

1) 2) 3)

C.

PROFESSIONAL AND BUSINESS EXPERIENCE:

Year Name of Establishment Position Held

1) 2) 3) 4)

To To To To

D.
Assets

TOTAL PERSONAL ASSETS & LIABILITIES:

Value (RM) Liabilities Owing to Banks Owing to Other Financial Institutions Other Liabilities ______________ ========== ______________ =========== Balance Owing (RM)

Landed Properties Shares In Public Companies Shares In Private Businesses Other Assets Total

NOTE:

Further details of Total Personal Assets and Liabilities are provided in the next page.

I hereby: i. certify that the particulars given in this form and any other information and documents or copies of documents enclosed herein or subsequently submitted are true and correct to the best of my knowledge. I further declare that there are no legal proceedings, current or intended instituted against me by any bank, financial institution or any other bodies. ii. expressly consent to and authorize you to disclose, as you shall in your absolute discretion deem fit, to Bank Negara Malaysia, any other bodies, authorise (CAGAMAS, debt collection agents) and the companies within MIDF Group including but not limited to their respective agents independent contractors and/or associates for the purpose of providing integrated services, maintaing records (financial or otherwise), marketing, distribution and/or other programmes at any time and without notice or liability, any information and particulars (financial or otherwise) relating to our affairs and accounts, facilities or conduct thereof. iii. authorise MIDF to verify the information and to conduct any necessary credit checking on my behalf from whatever sources deemed.

Signature : Name: Date: ..

*Delete whichever is not applicable

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1.

MAJOR LANDED PROPERTIES & OTHER ASSETS:

Address/Lot Identification/ Particulars Year of Purchase Purchase Cost (RM) Market Value (RM)

Type of Property/Other Assets

2.

HOLDINGS OF SHARES IN PUBLIC COMPANIES:

Name of Company Number of Shares Held

3.

HOLDINGS OF SHARES IN PRIVATE BUSINESSES:

Shareholdings Value (RM) %

Name of Co./Firm

Position Held

Type of Business

4.

MAJOR PERSONAL LIABILITES:

Type of Facility (e.g. Term Loan, OD etc) Amount Owing as at ..//

Name of Creditor Bank Or Institution

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