Attach A. Supplier Registration Form

SUPPLIER REGISTRATION FORM
Document No: FCN/PCM/SRF/01 Issue Date: 01.04.2010 Revision No: 01 Revision Date: 21/03/2012
ATTACHMENT A
APPLICATION FOR SUPPLIER REGISTRATION

1. 1.1 INSTRUCTION This Supplier Registration Form (SRF) is strictly for Fibrecomm Network (M) Sdn Bhd (Fibrecomm)s supplier registration only. The Supplier is required to fill in the Application for Supplier Registration Form and bind together with supporting documents stated in Part III to Fibrecomms Procurement and Contract Management Department in the following format: DOCUMENTS Cover Letter Supplier Registration Form Supporting Documents: APPENDIX A APPENDIX B APPENDIX C APPENDIX D APPENDIX E APPENDIX F APPENDIX G APPENDIX H APPENDIX I APPENDIX J Business Registration Form (Form D / Form 9) Memorandum and Articles of Association Form 24 Form 49 Latest Company Profile and Organization Chart Latest Three (3) Years Audited Financial Reports License / Certification With Authorities (e.g. MCMC, CIDB, PKK, MOF etc.) Works Category Major Customers Brochures and Catalogues
1.2
PART Part I Part II Part III
Please ensure that all documents have been certified true copy by your director/company secretary accordingly)
2. 2.1
TERMS AND CONDITIONS Acceptance and Rejection Fibrecomm reserves the right to accept or reject any SRF submitted by supplier. Registration with Fibrecomm does not indicate any award of project/job. Cancellation of Registration Fibrecomm reserves the right to cancel the suppliers registration without assigning any reason to the supplier. Changes Supplier is required to promptly inform Fibrecomm if there are any changes to the SRF, certificate and/or supporting documents submitted.
2.2
2.3
Page 1

SECTION 1: COMPANY INFORMATION 1. Company Name (in full) (Please attach Form D / Form 9 in APPENDIX A and Memorandum and Articles of Association in APPENDIX B) 2. Company Registration No. 3. Registered Address
KOMASI ENTERPRISE SDN BHD
107371-P 79, JALAN TERATAI 7 , TAMAN JOHOR JAYA, 81100 JOHOR BAHRU , JOHOR
4.
Correspondence Address (If different from the above)
Postcode:81100 79, JALAN TERATAI 7, TAMAN JOHOR JAYA , 81100 JOHOR BAHRU, JOHOR. Postcode:81100 30TH SEPT 1983 +607-3549851, +607-3530028 +607-3549855 www.komasi.com HJ HELAN BIN AWANG EXECUTIVE DIRECTOR 019-7352838 helan@komasi.com Sole Proprietorship Partnership Private Limited (Sendirian Berhad) Limited (Berhad) Foreign Yes
5. 6. 7. 8. 9.
10.
Date of Incorporation Telephone Number Facsimile Number Company Website URL Contact details Name Designation/Position Contact No. & E-mail Address Type of Incorporation (Please mark the appropriate field)
11.
12.
Bumiputra Status (Please tick which applicable and submit Bumiputra registration certificate issued by relevant authority i.e. MOF etc) Shareholders Interest (Note: S/H denotes Shareholding) (Please attach Form 24 in APPENDIX C)
No
13.
Directors (Please attach Form 49 in APPENDIX D)
Name: Hj Abd Aziz Bin Abd Majid Name: Hj Helan Bin Awang Name: Name: Name: Name: Name: Name: Hj Abd Aziz Bin Abd Majid Name: Hj Helan Bin Awang Name: Name:
% S/H : 80 % S/H : 20 % S/H : % S/H : % S/H : % S/H : % S/H :
Page 2
14.
Organizational Information (Please attach the latest organization chart in APPENDIX E)
Total number of employees: Management: ___6_______ Technical: ___34______ Admin: ___5_______ Others: ____8_______ Total: 53
15.
Financial Information Authorised Capital Paid Up Capital Financial Accounts (Please attach the latest 3 years Audited Accounts in APPENDIX F) Sales/Turnover (Please attach figures for the latest three( 3) years)
RM_5,000,000.00_______ RM_1,001,000.00_______
16.
1. RM 20416126____ 2. RM 18690325____ 3. RM 22464350_____
SECTION 2: REGISTRATION AND CERTIFICATION WITH AUTHORITIES 17. Registration and Type Approval Authority Name Registration Have you been registered or certified by Number a third party organization such as MCMC, CIDB, MOF etc. (Please attach a valid copy of the certificates in APPENDIX G)
Expiry Date
SECTION 3: PRODUCT AND SERVICES INFORMATION 18. Works Category Provide a brief summary of products and/or services offered by your company. You must have the valid authorization, legal rights and licenses to provide such products and services to Fibrecomm (Please mark the appropriate field and APPENDIX H)
19.
Major Customers (Please provide details of project undertaken with your major customers in APPENDIX I)
Name of Customer
Contact Person
Telephone No.
20.
Local Technical Support (Please provide your brochures and catalogues in APPENDIX J)
Facilities/manpower availability: ________________________ After sale services/technical support Storage Available ________________________ (If available, state location) Not Available
Page 3
SECTION 4: DECLARATION I/We (name) _HJ HELAN BIN AWANG______________as (designation) _EXECUTIVE DIRECTOR_ of (Company name) ____KOMASI ENTERPRISE SDN BHD__________________________________ 1. Certify that all information provided in this SRF and all supporting documents is true and correct to the best of our knowledge. 2. Certify there are no Fibrecomms employee working or holding any position in the company: 3. We acknowledge that there are: ex-Fibrecomm staff working or holding any position with our company. (If yes, please submit list of names, position held and date of joint). relative working or holding any position with our company. (If yes, please submit list of names, relationship, position held and date of joint). 4. Please confirm and tick one of the following boxes: We acknowledge that we are not a related party to Fibrecomm as defined in the Listing Requirement of Kuala Lumpur Stock Exchange (KLSE). We are to be considered as a related party of Fibrecomm for the following reason (please specify); ___________________________________________________________________________ ___________________________________________________________________________ 5. We confirm that in providing the information herein, we are not in breach of any obligation or secrecy or confidentiality or otherwise.
Signature: I/C No: 710115-01-6325 Date: 17-04-2012. Company Stamp ....
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APPENDIX H List of Works Category

Main Category A. SUPPLIES A1 A1.1 A1.2 A1.3 A1.4 A1.5 A1.6 A2 A3 A3.1 A3.2 A3.3 A3.4 A3.5 A3.6 A3.7 A3.8 A3.9 A3.10 A4 A5 A5.1 A5.2 A6 A7 A7.1 A7.2 A7.3 A7.4 A7.5 A7.6 A7.7 A7.8 A7.9 A7.10 A7.11 A7.12 A7.13 A7.14 A7.15 A7.16 A7.17 A8 A8.1 A8.2 SubCategory STATIONERY Office Stationery Computer Media Envelope Paper File Diary KITCHEN/GROCERIES/REFRESHMENTS/PANTRY/CATERING PRINTING Preprinted - File, Envelope, Booklet, Magazine Pamphlet, Memo Pad, Letterhead, Form Continuous Stationery and Computer Forms Label Sticker, Iron On (Plastic and Paper) Business Card and Greeting Card Poster, Banner, Bunting Hardcover Binding Softcover Binding Colour Separater Type Setting RECORDING EQUIPMENT AND MEDIA AUDIO VIDEO MOTOR VEHICLE Motor Vehicles Accessories SOUVENIR AND PROMOTIONAL ITEM CUSTOMER PREMISE EQUIPMENT AND SUPPORT SYSTEM PABX Equipment and Accessories Voice Over Internet Protocol (VOIP) Code Division Multiple Access (CDMA) Modilator-Demodulator (MODEM) Mobile Phone Caller ID PA System Digital Cordles Communication System Radio Communication System Data Communication System Lightning Arrestor Key Telephone System (KTS) Enhanced Private Branch Exchange (PABX) Equipment and Accessories Video Conferencing Equipment Analog Phone Digital Phone Network Terminal UNIFORMED MATERIAL Corporate Uniform Raincoat Page 5 Tick Here (/)
Description
A8.3 A8.4 A8.5 A8.6 A8.7 A8.8 A8.9 A9 A9.1 A9.2 A9.3 A9.4 A9.5 A9.6 A9.7 A9.8 A9.9 A9.10 A9.11 A9.12 A9.13 A9.14 A9.15 A9.16 A9.17 A9.18 A9.19 A9.20 A9.21 A9.22 A10 A10.1 A10.1.1 A10.1.2 A10.1.3 A10.1.4 A10.1.5 A10.1.6 A10.1.7 A10.1.8 A10.1.9 A10.2 A10.2.1 A10.2.2 A10.2.3 A10.2.4 A10.2.5 A10.2.6 A10.2.7 A10.2.8
Tie Scarf T-shirt Helmet Songkok Shoes Textile CIVIL, MECHANICAL AND ELECTRICAL ENGINEERING EQUIPMENT AND INFRASTRUCTURE Generating Set Generating Cable Accessories Primemover Centrifugal Pump Lightning and Earthing Protection System Battery and Rectifier System (For DC Power) Air-conditioned System Tower, Guyed Mast, Monopole, Mini Structure Cabin / Shelter Mechanical and Electrical Appliances Un-interrupted Power Supply (UPS) Diesel and Lubricant Oil Test Gear Transformer AC Transmission Systems AC Distribution Systems Congeneration Main Switch Board CGPA GPA Compressor Dryer Water Pumps TELECOMM/NETWORK EQUIPMENT AND ACCESSORIES Telecommunication Equipment and Accessories Switching Equipment International Gateway Tandem, Local, ATM, Mobile, Softswitch Transmission Equipment: SDH Equipment for Fibre Microwave, PDH, Multiplexer, Compressor TV/Radio Transmission Equipment Data Communication Equipmt (IDNX, X_25) Satellite and Broadcast Communication Equipment Access Network Equipment : Wired Access Network Equipment : Wireless Cable and Accessories Fibre Optic Cable Fibre Optic Cable Accessories Copper Cable Copper Cable Accessories RF/Coaxial Cable and Accessories Connector, Surge Arrestor, Attemator Outside Plant Materials Poles (Iron, Concrete, Wood) Page 6
A10.2.9 A10.2.10 A10.3 A11 A12 A13 A14 A14.1 A14.2 A14.3 A14.4 A14.5 A14.6 A14.7 A14.8 A14.9 A14.10 A14.11 A14.12 A15 A15.1 A15.2 A15.3 A15.4 A15.5 A15.6 A16 A16.1 A16.1.1 A16.1.2 A16.1.3 A16.1.4 A17 A17.1 A17.2 A18 A18.1 A19 A20 A20.1 A20.2 A20.3 A20.4 A20.5 A20.6 A20.7 A20.8 A20.9 A20.10 A20.11 A21
Pipes Poles Accessories Telecommunication Test Equipment and Accessories EXHIBITION BOOTH QUEUE MANAGEMENT EQUIPMENT AND SYSTEMS OFFICE FURNITURE, FITTING AND FIXTURE OFFICE EQUIPMENT AND AIDS Scanner Laminating Counting Machine Photostat TV Calculator Printer Shredder LCD Fax Toner Cartridge Data Tape SECURITY AND LOSS CONTROL CCTV and Duress Alarm Monitoring & Protection System (MAPS) Fire Fighting Equipment and System Fire Extinguisher Security Card Security Equipment SAFETY AND HEALTH Personal Protective Equipment Safety Shoes First Aid Kit Helmet and Torchlight Safety Belt SIGNAGE Outdoor Signage Indoor Signage CARD Smart Card PRODUCT PACKAGING INFORMATION TECHNOLOGY (IT) HARDWARE AND SOFTWARE PC, Notebook, Workstations and Related Peripheral Small to Large Multi-user Systems Software Product Other Computer Related Item Networking Products IT Security Equipment Uninterruptible Power Supply (UPS) Router Magnetic Tape Cartridge Storage INTERNET SERVICE PROVIDER HARDWARE AND SOFTWARE Page 7
A21.1 A21.2 A21.3 A21.4 A22 A22.1 A22.2 A22.3 A22.4 A23 A24 A25 A26 A27 B1 B2 B3 B5 B6 B7 B8 B9 B10 B11 B12 B13 B14 B15 B16 B17 B18 B19 B20 B22 C. SERVICES C1 C1.1 C1.2 C1.3 C2 C3 C4 C5 C6 C7 C8 C8.1 C8.2
ISP Equipment and Related Peripheral ISP Software Product and Services ISP Networking Product and Services ISP Satellite Communication Equipment INTERNET PROTOCOL THONY H/WARE & S/WARE IPT Equipment and Related Peripheral IPT Software Product and Services IPT Networking Product & Services IPT Satellite Communication Equipment TOOLS EQUIPMENT ADVERTISING EQUIPMENT SPORTS EQUIPMENT OUTDOOR ADVERTISING BOOK / MAGAZINE / NEWSPAPER ARCHITECTURAL CIVIL STRUCTURE, MECHANICAL & ELECTRICAL CONSULTANT SURVEYOR TRANSLATOR QUALITY CONSULTANT EVENT MANAGEMENT AND PUBLIC RELATION CONSULTANT IT SPECIALIST / CONSULTANT TRAINING CONSULTANT FINANCIAL CONSULTANT / AUDIT CONSULTANT RESEARCH AGENCY PROPERTY DEVELOPMENT / CONSULTANT INTERIOR DESIGN CONSULTANT ONE STOP AGENCY-TELECOMMUNICATION DATA ENTRY AGENCY SOIL INVESTIGATION RISK MANAGEMENT REGULATORY CONSULTANT OTHER PROFESSIONAL SERVICES PROFESSIONAL PHOTOGHARPHER LOSS ADJUSTER ADVERTISING Agency Multimedia Services Recording Services TAILORING SERVICES LAUNDRY SERVICES SECURITY SERVICES MEDICAL SERVICES BILLING MAILING HOUSE SCRAP DEALER BUILDING MAINTENANCE SERVICES Office Premises Maintenance Parking Page 8
B. PROFESSIONAL SERVICES
C8.3 C8.4 C8.5 C8.6 C8.7 C8.8 C8.9 C8.10 C8.11 C9 C9.1 C9.2 C9.3 C9.4 C9.5 C9.6 C9.7 C10 C11 C11.1 C11.1.1 C11.1.2 C11.2 C11.3 C11.4 C11.5 C11.6 C11.7 C12 C12.1 C12.2 C12.3 C12.4 C13 C13.1 C13.11 C13.1.2 C13.1.3 C13.1.4 C14 C15 C15.1 C15.2 C16 C17 C18 C23 C24 C25 D. WORKS D2
Lift Installation and Maintenance Electrical and Mechanical Maintenance Plumbing Hygiene Service Pest Control Services Landscaping Lawn Internal Wiring Telephone Installation/ Maintenance LAN and WAN Cabling Installation and Maintenance TRANSPORTATION AGENCY AND WAREHOUSE SERVICE Packer and Mover (Admin) Sea, Air and Land Travel Freight Forwarder and Custom Clearing Agent Packer and Mover (Logistic) Warehouse Towing Services Crane / Low Loader Services DOCUMENT STORAGE SERVICES RENTAL Motor Vehicles Forklift Crane Office Equipment PA System Office Furniture and Fitting Civil, Mechanical and Electrical Engineering Equipment Generator Set Satelite and Broadcast Communication Equipment OFFICE EQUIPMENT REPAIR AND MAINTENANCE SERVICES Office Equipment Repair and Maintenance Office Air-condition Repair and Maintenance Refurbishment of Office Furniture Refurbishment of Fitting and Fixture WORKSHOP Vehicle Repair and Services Accident Repair General Services Air-Condition Servicing Tyre TRAVEL AGENCY MAILING SERVICES Corporate Mailing Services Courier Service CONTACT CENTRE SERVICES ENTERTAINMENT DEBT COLLECTION AGENCY HOTEL/RESORT/REST HOUSE EMPLOYMENT AGENCY DIGITAL MEDIA AND INTERACTIVE SERVICES CIVIL STRUCTURE ENGINEERING Page 9
D2.1 D2.2 D2.3 D2.4 D2.5 D3 D3.1 D3.2 D3.3 D4 D4.1 D4.2 D4.3 D4.4 D4.5 D4.6 D4.7 D4.8 D4.9 D4.10 D5 D5.1 D5.1.1 D5.1.2 D5.1.3 D5.1.4 D5.2 D5.2.1 D5.2.2 D5.2.3 D5.3 D5.3.1 D5.3.2 D5.3.3 D5.4 D5.4.1 D5.4.2 D5.5 D6 D6.1 D6.2 D6.3 D6.4 D6.5 D6.6 D6.7 D6.8
Road & Bridge Construction and Repair Slope/Landslide/Erosion Protection Slope/Landslide/Erosion Construction and Repair Structure / Cabin / Shelter Repair Room Renovation BUILDING CONSTRUCTION, REPAIR AND RENOVATION Building Construction Interior Renovation Services General Building Repair and Services MECHANICAL AND ELECTRICAL ENGINEERING Air Conditioning and Ventilation System Fire Prevention and Protection System Generator AC Mechanical and Electrical Appliances DC Power (Rectifier & Battery), UPS Sub-Station Towers, Guyed Mast, Monopole and Mini Structure Cabin / Shelter Lightning and Earthing Protection System Building Wiring TELECOMMUNICATION WORK Outside Plant Trenching Work Services Fiber Cable Network Services Copper Cable Network Services Outside Plant Materials Inside Plant Access Network Equipment Installation and Maintenance Service Transmission Equipment Installation and Maintenance Service Switching Equipment Installation and Maintenance Service Microwave Network Microwave Equipment Installation and Commissioning Service Microwave Transmission Equipment Installation and Commissioning Service Satellite Transmission Equipment Installation, Commissioning and Decommissioning Service Mobile Access Network Services Mobile Access Equipment Installation and Commissioning Service Mobile Access Infrastructure and Cabling Telecommunication Equipment Part Repair IT HARDWARE AND SOFTWARE PC, Notebook and Related Peripheral and Service Small to Large Multi-user Systems and Service Software Product and Services Other Computer Related Services Networking Products and Services IT Security Equipment and Services Uninterruptible Power Supply (UPS) Router
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CHECK LIST OF ENCLOSURES REQUIRED: Please ensure that all relevant documents/certificate/license listed below are attached together with SRF before submitting it. SRF with missing attachment will be rejected. The checklist is for your guidance only. APPENDIX A APPENDIX B APPENDIX C APPENDIX D APPENDIX E APPENDIX F APPENDIX G Business Registration Form (Form D / Form 9) Memorandum and Articles of Association Form 24 Form 49 Latest Company Profile and Organization Chart Latest Three (3) Years Audited Financial Reports License / Certification With Authorities (e.g. MCMC, CIDB, PKK, MOF etc.) Works Category Major Customers Brochures and Catalogues
APPENDIX H APPENDIX I APPENDIX J
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Attach A. Supplier Registration Form

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SUPPLIER REGISTRATION FORM

APPLICATION FOR SUPPLIER REGISTRATION

PART Part I Part II Part III

SUPPLIER REGISTRATION FORM

SUPPLIER REGISTRATION FORM

KOMASI ENTERPRISE SDN BHD

Correspondence Address (If different from the above)

Directors (Please attach Form 49 in APPENDIX D)

% S/H : 80 % S/H : 20 % S/H : % S/H : % S/H : % S/H : % S/H :

SUPPLIER REGISTRATION FORM

Organizational Information (Please attach the latest organization chart in APPENDIX E)

1. RM 20416126____ 2. RM 18690325____ 3. RM 22464350_____

SUPPLIER REGISTRATION FORM

Signature: I/C No: 710115-01-6325 Date: 17-04-2012. Company Stamp ....

SUPPLIER REGISTRATION FORM

APPENDIX H List of Works Category

SUPPLIER REGISTRATION FORM

SUPPLIER REGISTRATION FORM

SUPPLIER REGISTRATION FORM

SUPPLIER REGISTRATION FORM

SUPPLIER REGISTRATION FORM

SUPPLIER REGISTRATION FORM

APPENDIX H APPENDIX I APPENDIX J

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1. RM 20416126 2. RM 18690325 3. RM 22464350_