Please fill in the form according to the Registrar of Company (ROC). Please tick () the box where applicable
* Mandatory field
A. CUSTOMER INFORMATION
*COMPANY NAME
AGENT CODE
WEBSITE:
If your company is a subsidiary, please state your parent company name according to the Registrar of Company (ROC).
ROC NO:
Yes
No
*COMPANY TYPE:
Berhad
Sdn. Bhd.
Semi Government
Enterprise
MNC
SME
Public Listed
Financial Services/Insurance
Agriculture
Educational
Manufacturing
Utilities
Professional Services
Retail
ICT
Hotel / Entertainment
*BUSINESS FUNCTION: You can tick () more than one where applicable.
Forwarding Agent
Shipping Agent
Freight Forwarder
Trader
Insurance Agent
Importer (Consignee)
Exporter (Consignor)
Port Authority
Warehousing
Movers
Courier Services
Port Operator
Hauliers
CONTACT DETAILS
* Tun / Tan Sri / Datin Sri / Puan Sri / Dato Sri / Datuk Seri /
Dato / Datuk / Datin / Prof. / Prof. Madya / Dr. / Ir / Tuan /
Puan / Encik / Cik / Haji / Hajjah / Mr. / Miss / Ms.
(Please circle)
* Name:
* REGISTERED ADDRESS
(Head of Company)
Designation:
* Postcode:
))Gender:
Email:
* State:
ext
Secretary/ PA Name:
* Country:
* Tel No. : (
)-
* Fax No. : (
)-
Yes
If Yes, please provide your mobile phone number or email address in the
allocated field above.
Selangor
KLIACVC
Johor
Melaka
Negeri Sembilan
Perak
Penang
Kedah
Perlis
Pahang
Terengganu
Kelantan
Sabah
Sarawak
WP Labuan
WP Putrajaya
WP Kuala Lumpur
No
C. PRODUCT INFORMATION
Please tick ( ) the required purchased product(s) below. You can tick ( ) more than one where applicable.
(1) eDeclare
* Message Type:
Package 1 - K1, K1A, K2, K3, K8 and K9
Package 2 -ZB1, ZB2, ZB3 and ZB4 for AIR MODE ONLY
(2) eManifest
Package for K4, K5, K6 and CUSREP
(3) ENTERPRISE APPLICATION INTEGRATION (EAI)
* Message Type (please specify):
CUSREP
Cuscar K4
Cuscar K5
Cuscar K6
IFTDGN
K1
K2
K9
K3
K8
ZB1
ZB2
ZB3
ZB4
K4PAM
(4) ePermit
K6DMP
*Please tick ( ) agency name. You can tick more than one where applicable.
Department of Environment
Energy Commission
Trader
eValue Plan
Manufacturer
Standard Plan
(6) ePayment
Financial Services Payment Gateway (FSPG)
DutyNet
*Payer Bank:
(7) BUSINESS PARTNERS SOFTWARE:
Rank Alpha Technologies Sdn Bhd
Wynet Computer Sdn Bhd
Mobile Force Software (M) Sdn Bhd
Others:
*D. CONNECTIVITY INFORMATION
Time DotCom
Jaring
Maxis
TM Net
Others:
Dial Up
Internet
Lease Line
ISDN
Others:
ASP
HTTPS
Others:
* BILLING ADDRESS
Same as above?
Same as above?
Yes
Yes
No (please fill up the following details)
*Name:
*Designation:
*Department:
* DID Tel No.: (
* City/Town:
* Postcode:
* State:
Email:
)-
ext
)Gender:
* Country:
* Tel No :
* Fax No:
* Mode of Payment
By Mail
Over Counter at
Kedai EDI
Maybank
CIMB
Direct Bank In
Internet Banking
RHB
Others:
No
* F.
Installation Address
Same as previous :
*
*
Yes
*Postcode:
*State:
* Country:
* Tel No.: (
)-
* Fax No.: (
)-
**Note: Please provide copy of Free Zone license if you are operating within Free Zone Area for 5% service tax exemption purposes.
Please tick () the box where applicable.
FCZ
FIZ
***Note: To receive notifications from DNT, please provide your mobile number and email address in the allocated field below
NAME OF STAFF
MOBILE NO
IMPORT DEPARTMENT
1.
2.
EXPORT DEPARTMENT
1.
2.
TRANSHIPMENT DEPARTMENT
1.
2.
EMAIL ADDRESS
(name of Company)
I/We
having a principal office at
hereby agree to be bound by the terms and conditions as provided in this Agreement as the same may, by notification, be amended
or supplemented from time to time.
Signature :
Date :
Company Stamp:
PAYMENT RECEIVED
Form 9
Registration Fee
Total Received
EDI Mailbox No
Remarks :
Account No
Service Activation Date
Billing Activation Date
Installation Date
Verified and confirmed by
Approved by
Remarks :
Signature
Date
AMOUNT(RM)
GENERAL
1. The terms and conditions of this Agreement are binding on
all Subscribers and a Subscriber shall also be deemed to
have contracted with all other Subscribers and are bound by
the terms and conditions of this Agreement.
a)
b)
c)
d)
APPLICABLE CHARGES
8.
CONFIRMATION OF RECEIPT
SCOPE OF SERVICES
9.
NETWORK SERVICES
a)
b)
LIABILITIES
DISPUTES
16.
17.
18.
19.
20.
SECURITY
AUDIT
12.
13.
14.
DUTY
OF
AGREEMENT
AND