Fillable THIRD SCHEDULE (Subperaturan 6(1)/Subregulations 6(1)) BORANG A/FORM A

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THIRD SCHEDULE (Subperaturan 6(1)/Subregulations 6(1)) BORANG A/FORM A

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THIRD SCHEDULE
(Subperaturan 6(1)/Subregulations 6(1))
BORANG A/FORM A
AKTA KOMUNIKASI DAN MULTIMEDIA 1998/
COMMUNICATIONS AND MULTIMEDIA ACT 1998
PERATURAN-PERATURAN KOMUNIKASI DAN MULTIMEDIA (PELESENAN)/
COMMUNICATIONS AND MULTIMEDIA (LICENSING) REGULATIONS 2000
PERMOHONAN UNTUK LESEN INDIVIDU/
APPLICATION FOR INDIVIDUAL LICENCE
Tandakan (√ ) mana-mana yang berkenaan
Tick (
√
) whichever is applicable
1. Permohonan untuk*
Application for*
(a) lesen kemudahan rangkaian
network facilities licence
(b) lesen perkhidmatan rangkaian
network service licence
(c) (deleted)
(d) lesen perkhidmatan aplikasi kandungan
content applications service licence
2. Jenis permohonan
(a) permohonan baru
new application
(b) pembaharuan
renewal
*NOTA: Permohonan untuk dua lesen atau lebih hendaklah dibuat dalam borang permohonan yang
berasingan, setiap satunya disokong dengan maklumat yang berkaitan.
*NOTE: An application for two or more licences shall be made in separate application forms, each
supported by the relevant information.
A. BUTIR-BUTIR PEMOHON
PARTICULARS OF APPLICANT
1. Nama Pemohon dan No. Syarikat
Name of applicant and Company No.
2. Pejabat Berdaftar
Registered office
No. Telefon
Telephone No.
No. Faks
Fax. No.
3. Tempat perniagaan utama
Principal place of business
No. Telefon
Telephone No.
No. Faks
Fax. No.
4. Butir-butir pemegang saham pemohon*
Particulars if shareholding of the applicant*
Nama
Name
No. KP/
No. Paspot/
No. Syarikat
NRIC No./
Passport No./
Company No.
Alamat
Address
Jumlah dan %
saham yang
dipegang
Number and % of
shares held
*Sila nyatakan pemegang saham benefisian terakhir
*Please indicate ultimate beneficial shareholder
5. Adakah pemohon kini memegang apa-apa penguntukan spektrum, penguntukan radas atau
penguntukan kelas?
Does the applicant currently hold a spectrum assignment, apparatus assignment or a class
assignment?
Jika ya, sila berikan butir-butir
If yes, please provide particulars
Ya / Yes
Tidak / No
6. Adakah pemohon telah diuntukkan apa-apa nombor atau apa-apa alamat elektronik?
Has the applicant been assigned any numbers or any electronic addresses?
Jika ya, sila berikan butir-butir
If yes, please provide particulars
7. Adakah pemohon membuat apa-apa usahasama?
Has the appliacnt entered into any joint ventures?
Jika ya, sila berikan butir-butir
If yes, please provide particulars
8.
(a) Pernahkan pemohon diberikan lesen di bawah Akta Telekomunikasi 1950?
Has the applicant been licensed under the Telecommunication Act 1950?
(b) Pernahkah pemohon diberikan lesen di bawah Akta Penyiaran 1988?
Has the applicant has been licensed under the Broadcasting Act 1988?
9. Adakah lesen pemohon di bawah subperenggan 8(a) atau (b) pernah digantung atau
dibatalkan?
Was the applicant's licence under subparagraph 8(a) or (b) ever suspended or revoked?
Jika ya, sila berikan butir-butir
If yes, please provide particulars
Ya / Yes
Tidak / No
Ya / Yes
Tidak / No
Ya / Yes
Tidak / No
Ya / Yes
Tidak / No
Ya / Yes
Tidak / No
B. PENGAKUAN
DECLARATION
1. Adakah penerima, atau penerima dan pengurus, pernah dilantik berkenaan dengan apa-apa
harta pemohon?
Has a receiver, or receiver and manager, been appointed in respect of any of the applicant's
assets?
2. Adakah pemohon telah mencapai kata sepakat atau membuat perkiraan dengan pemiutang?
Has the applicant entered into a compromise or arrangement with creditors?
3. Adakah petisyen telah dikemukakan ke mahkamah untuk menggulungkan pemohon?
Has a petition been presented in court for the winding up of the applicant?
C. MAKLUMAT
INFORMATION
1. Maklumat dua orang iaitu dua pengarah atau seorang pengarah dan setiausaha syarikat
pemohon yang boleh dihubungi untuk maklumat lanjut:
Particulars of two persons namely two directors or a director and the company secretary of
the applicant who may be contacted for further information:
Nama
Name
Jawatan
Position
No. Telefon
Telephone No.
Alamat
Address
2. Apa-apa maklumat tambahan yang dianggap berkaitan dengan permohonan ini:
Any additional information considered relevant to this application:
Ya / Yes
Tidak / No
Ya / Yes
Tidak / No
Ya / Yes
Tidak / No
Kami, , pemohon, dengan
ini mengaku daan mengesahkan bahawa kami layak memohon untuk mendapatkan lesen individu
ini di bawah Akta dan semua maklumat yang diberikan dalam permohonan ini dan dalam lampiran
yang dikepilkan adalah benar dan tepat.
We, , the applicant,
declare and confirm that we are eligible to apply for an individual licence under the Act and that
all the information given in this application and in the attached annexes is true and accurate.
Tarikh:
Date:
Ditandatangani oleh:
Signed by:
Untuk dan bagi pihak:
for and on behalf of:
NOTA:
NOTE:
Jika ruang yang disediakan tidak mencukupi untuk memberikan butir-butir, sila kepilkan lampiran.
Setiap lampiran mestilah ditandatangan ringkas oleh seorang yang menandatangani permohonan ini.
If the spaces is insufficient to provide the particulars, please attach annexes. Any annex should be
initialled by the signatory to this application.
Tandatangan disini
Sign here
Borang ini boleh dimuat turun di www.skmm.gov.my
This form can be downloaded from www.skmm.gov.my
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THIRD SCHEDULE (Subperaturan 6(1)Subregulations 6(1)) BORANG AFORM A

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Completed 9 July 2021

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