Fillable Smartpay Application Form (Petronas Selangor)

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Smartpay Application Form (Petronas Selangor)

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PROJECT ROVER
PETRONAS DAGANGAN BERHAD,
Ground Floor, The Place @ Ampang,
PT27423 (Lot 36904), Jalan Kolam Air Lama,
68000 Ampang, Selangor
B.
BUSINESS TYPE
JENIS PERNIAGAAN
NATURE OF BUSINESS
SIFAT PERNIAGAAN
C.
D.
THIRD PARTY DEPOSITOR
PENDEPOSIT PIHAK KETIGA
TYPE OF BUSINESS
JENIS PERNIAGAAN
(COMPANY / INDIVIDUAL)
NAME
COMPANY REGISTRATION /
IDENTIFICATION NO
CONTACT NO
NAMA
NO PENDAFTARAN SYARIKAT
NO KAD PENGENALAN
NO UNTUK DIHUBUNGI
(SYARIKAT / PERSENDIRIAN)
(Applicable only if the details differ from the above)
MONTHLY STATEMENT PREFERENCES
i. Softcopy (Download from SPO Portal
ii. Softcopy (E-Mail and SPO)
iii. Hardcopy (Fee of RM10/month)
PLEASE SELECT ONE
PLEASE SELECT ONE
F.
E.
G.
STANDALONE
Persendirian
FLEET MANAGER
Pengurus Kenderaan
VEHICLE CARD
Kad Kenderaan
DRIVER CARD
Kad Pemandu
PETROL RON97
PETROL RON95
DIESEL
LUBRICANT
Minyak Pelincir
KEDAI MESRA
10
DAILY
Harian
4
5
6
7
8
9
PRODUCT CATEGORY
Kategori Product
Card TYPE
Jenis Kad
CARD INFORMATION
( Please print/copy this page if you would like to request more than 10 cards)
MAKLUMAT KAD
(Sila cetak/buat salinanmukasurat ini jika anda ingin memohon lebih dari 10 kad)
1
2
3
MONTHLY
Bulanan
TRANSACTION COUNT LIMIT
Had Kiraan Transaksi
ODOMETER
READING
(Y/N)
Bacaan
Odometer
(Ya/Tidak)
COST CENTRE
Pusat
Tanggungjawab
Pls indicate SEQ. only -
refer Section H)
PURCHASE LIMIT (RM)
Had Pembelian (RM)
MONTHLY
Bulanan
NO
NAME TO APPEAR ON CARD
Nama Yang Akan Tertera Pada Kad
VEHICLE NO.
No. Pendaftaran Kenderaan
SINGLE
TRANSACTION
Had Satu Transaksi
DAILY
Harian
KNOW YOUR COUNTERPARTY QUESTIONNAIRE
The PETRONAS Code of Conduct and Business Ethics (“CoBE”) sets out PETRONAS’ core principles with respect to ethics and integrity, competition, sanction and export
control, and data privacy.
As part of our commitment, PETRONAS expects its contractors, subcontractors, consultants, agents, representatives and others performing work or services for or on
behalf of the Group to comply with all applicable laws and the relevant parts of the CoBE and any other relevant guidelines or manual when performing such work or
services.
Therefore, before PETRONAS engages a third party, we are obligated to conduct appropriate third party due diligence to understand the business and background of
our prospective business counter parties to ensure that we are dealing with parties that subscribe to the same values and ethical standards of integrity as PETRONAS in
the conduct of their business.
Please complete the following questionnaire, using additional pages where necessary, and return a scanned, signed copy to the PETRONAS focal person in charge. If
you subsequently learn that any of the information provided below is incorrect or incomplete, please correct or complete it (as applicable) and notify us as soon as
possible.
SECTION A: COMPANY
QUESTIONS
RESPONSE
1
Please provide the following details:
a. Shareholder(s);
b. Ultimate beneficial owner(s);
c. Percentages held and jurisdiction/nationality of each
shareholder; and
d. Jurisdiction(s) of residence of each ultimate beneficial owner(s)
.
2
Please provide the following details of each current director:
a. Full Name
b. Nationality
c. Date of
Birth
NAME
NAMA
NATIONALITY
DATE OF BIRTH
WARGANEGARA
TARIKH LAHIR
NAME
NAMA
NATIONALITY
DATE OF BIRTH
WARGANEGARA
TARIKH LAHIR
NAME
NAMA
NATIONALITY
DATE OF BIRTH
WARGANEGARA
TARIKH LAHIR
NAME
NAMA
NATIONALITY
DATE OF BIRTH
WARGANEGARA
NAME
NAMA
NATIONALITY
DATE OF BIRTH
WARGANEGARA
Please upload an attachment for company with more than 5 directors
NO
3
List of “key” employees, contractors and consultants of the Company who will be involved
with or has an existing commercial relationship with PETRONAS.
4 Does the Company outsource or intend to outsource any of its services in relation to the
proposed arrangement with PETRONAS?
If yes, please set out details of the third party contractors. Please note that any outsource
arrangement in relation to the transaction requires PETRONAS prior consent.
SECTION B:
ETHICS
QUESTIONS
RESPONSE
1.
Are any of the current directors or current key employees of the Company also a Public
Official? If so, please provide details.
DESCRIPTIONS
For ease of reference, “Public Official” shall include the following:
(i) a person employed by a public authority holding a legislative, executive,
administrative or judicial office, whether appointed or elected, whether permanent
or temporary, whether paid or unpaid, irrespective of that person’s seniority;
(ii) any other person who performs a public function, including for a public agency or
public enterprise, or provides a public service; or
(iii) any other person defined as a “public official” in the domestic law of a country.
2.
Please disclose any relationship which the Company, its affiliates, its directors and/or key
employees has or have with any Public Official related to the transaction.
3.
Have any payments been made by or on behalf of the Company during the past five years to
any Public Official?
If so, please provide details.
4.
Does the Company has any affiliation with current PETRONAS employee who is involved
in this transaction?
If yes, please provide details:
• Full Legal Name of the
Individual
• Position Held
• The Duty/Duties of the
Position(s)
• Tenure (start & end dates)
NO
5.
Does any government, its agencies or controlled organisations, or any other organisation
performing a governmental function own any interest in or exercise any control over the
Company’s business?
If Yes, please list the nature and extent of any such interest or control.
SECTION B: ETHICS
NO
QUESTIONS
RESPONSE
6.
Does the Company have and disseminate to its employees the following:
i) a written employee code of conduct;
ii) a written anti-bribery and corruption policy; and
iii) a policy and process for reporting bribery if discovered?
7.
Has the Company (or any of its affiliates, shareholders, directors or key employees) ever
been the subject of any convictions or prosecutions, or is the subject of any pending
investigations by public authority, in relation to bribery or corruption? Provide details, if any.
8. Does the Company require its contractors, sub-contractors and other third parties to comply
with its ethics and compliance policies (including anti-bribery and corruption)?
If Yes, please
provide
details
to
what
extent
does
the
Company
monitor
the
integrity
of
its
third
parties.
9.
Has the Company (or any person or entity listed in this questionnaire) ever been barred from
competing for government contracts in any country?
If Yes, please provide details.
SECTION C: SANCTIONS & EXPORT CONTROL
NO
QUESTIONS
RESPONSE
1.
Is the Company or any of its affiliates are incorporated, located within or operating from
any countries subject to Comprehensive Sanctions?
If yes, please specify.
Definitions:
“Sanctions” means all laws or regulations concerning
economic sanctions
(including embargoes, export restrictions, restrictions on the ability to make or
receive international payments, freezing or blocking of assets of targeted Persons, or
the ability to engage in transactions with or involving specified Persons or
countries, or any laws or regulations threatening to impose economic sanctions on
any Person for engaging in targeted behaviour) of any jurisdictions including –
(a) the United Nations;
(b) Malaysia;
(c) the European Union;
(d) the United Kingdom (including those administered by HM Treasury);
(e) the United States (including those administered by the Office of Foreign Assets
Control of the Department of the Treasury, the Bureau of Industry and Security of
the Department of Commerce, or the Department of State);
“
Country Subject to Comprehensive
Sanctions” as at June 2018:
(a) Cuba;
(b) Iran;
(c) Venezuela;
(d) North Korea;
(e) Syria; and
(f) Crimea
Region.
“Person” means any natural person, corporation, limited liability company, trust,
joint venture, association, company, partnership, Governmental Authority or other entity.
2.
Is the Company or any of its affiliates are engaged in transactions,
investments, business or other dealings that directly or indirectly involve or benefit any
countries subject to Comprehensive Sanctions or any person or entity which is the
target or subject of any Sanctions.
If yes, please specify.
3.
4.
Has the Company ever been the subject of any convictions or prosecutions, or is it
the subject of any pending investigations by a public authority, in relation to
economic sanctions & export control regulations?
If yes, please provide details.
Are any of the goods and/or services that will be supplied an item subject to export control,
such as the controls as prescribed under Strategic Trade Act 2010, the U.S Export
Administration Regulations or any other similar export control laws?
SECTION D:
NOTICE OF DISCLOSURE (For PETRONAS Use)
Personal Data Protection Act 2010 (“PDPA 2010”)
Pursuant to the enforcement of PDPA 2010, we hereby wish to give this notice and seek your consent on the processing of your personal data as well as to give an
assurance of our commitment to ensure that your data is securely processed, kept and not used or disclosed for any other purpose than the commercial dealings we
have with you. The contact to whom written requests for access to personal data or correction and/or deletion of personal data or for information regarding policies
and procedures and types of personal data handled by us can be made to the following:
CONTACT NO
NAMA PETUGAS PETRONAS
NO UNTUK DIHUBUNGI
E-MAIL ADDRESS
ALAMAT E-MEL
SECTION E:
CERTIFICATION
By signing this document, the undersigned, being duly authorized to complete this questionnaire, hereby certify the following:
______________
Date
For and on behalf of (INSERT COMPANY NAME)
Signed by the authorized representative of the Company:
_________________________________________
Signature
Name:
Designation:
Name of PETRONAS Officer
o declares that he/she has, or has obtained from the relevant authority, the proper mandate and authority to disclose such information;
o consents to the processing of such information for the purpose described in the Notice of Disclosure;
o acknowledges that the processing of such information may be conducted by a third party on behalf of PETRONAS which may occur in another country
than the country of disclosure; and
o represents that the information provided in this document is, to the best of his/her knowledge is accurate, current and complete as of the date of
disclosure.
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Smartpay Application Form (Petronas Selangor)

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Completed 10 August 2020

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