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					                                                                     BORANG/FORM AJL-1

                 PERATURAN-PERATURAN JUALAN LANGSUNG 1993
                       (DIRECT SALES REGULATIONS 1993)

                                        Peraturan 3
                                       (Regulation 3)

                    PERMOHONAN UNTUK MENDAPATKAN LESEN
                         (APPLICATION FOR A LICENCE)

Pengawal Jualan Langsung,
Kementerian Perdagangan Dalam Negeri
Dan Hal ehwal Pengguna,
Bahagian Perdagangan Dalam Negeri,
Aras 4, Lot 2G3, Presint 2,
Pusat Pentandiran Kerajaan Persekutuan,
62623 PUTRAJAYA.

Tuan/(Sir),

Saya/Kami, …………………………………………………………………………………….
(I/We              Nama Syarikat (Name of Company)

ingin memohon mendapatkan lesen untuk menjalankan perniagaan jualan langsung.
(wish to apply for a licence to carry on a direct sales business.)

NOTA:
(NOTE):

       Jika ruang yang disediakan tidak mencukupi untuk memberi perincian, sila gunakan
       lampiran. Setiap lampiran mestilah ditandatangani oleh pemohon.
       (If the space provided is not sufficient to provide details, please attach annexure(s).
       Each annexure must be signed by the applicant.)


1.     BUTIR-BUTIR SYARIKAT
       (PARTICULARS OF COMPANY)

       (a)    Alamat Berdaftar:
              (Registered Address):

              …………………………………………………………………………………..

              …………………………………………………………………………………..

              No. Telefon: ……………………………………………………
              (Telephone No.):

              No. Telefaks: …………………………………………………..
              (Telefax No):




                                                                                            1
(b)   Alamat Surat-menyurat:
      (Correspondence Address):

      …………………………………………………………………………………..

      …………………………………………………………………………………..

      No. Telefon: ……………………………………………………
      (Telephone No.):

      No. Telefaks: …………………………………………………..
      (Telefax No):

(c)   No. Pendaftaran Syarikat: ……………………………………………………..
      (Company’s Registration No.):

(d)   Tarikh Pendaftaran: ……………………………………………………………..
      (Registration Date);

(e)   No. Lesen Perniagaan (Dewan Bandaraya/Majlis Perbandaran):
      (Business Licence No. (City Hall/Municipality):

      ………………………………………………….

(f)   No. Cukai Pendapatan Syarikat: ……………………………………………...

(g)   Jenis Perniagaan Yang Didaftarkan:
      (Company’s Income Tax No.):

      …………………………………………………………………………………..

      …………………………………………………………………………………..

      …………………………………………………………………………………..

(h)   Perniagaan Utama dan Bidang Operasi:
      (Principal Business and Field of Operations):

      …………………………………………………………………………………..

      …………………………………………………………………………………..

      …………………………………………………………………………………..

(i)   Alamat Tempat Perniagaan (termasuk semua cawangan dan pembekal):
      (Address of Business Premise (including all branches and stockists):

             Alamat                         No. Telefon        No. Telefaks
             (Address)                      (Telephone No.)    (Telefaks No.)

      ………………………………….. …………………….                           ……………….

      ………………………………….. ……………………..                          ……………….




                                                                                2
2.   STRUKTUR MODAL
     (CAPITAL STRUCTURE)


     (a) Modal        (i) Dibenarkan:              RM …………………………..
         (Capital)        (Authorised):

                      (ii) Berbayar:               RM …………………………..
                           (Paid-up):

                      (iii) Modal Kerja:           RM …………………………..
                            (Working Capital):


     (b) Kemudahan Kewangan
         (Financial Facilities)

               Jenis Sumber                         Institusi       Amaun (RM)
             (Type of Sources)                    (Institution)    (Amount RM))

          (i) ………………………                 ………………………………….            ………………………
                                                                  .

          (ii) ………………………                ………………………………….            ………………………
                                                                  .

          (iii)……………………                 ………………………………….            ………………………
                                                                  .

     (c) Akaun Syarikat
         (Company’s Accounts)

                 Nama Bank                         Alamat            No. Akaun
               (Name of Bank)                     (Address)        (Account No.)

          (i) ………………………                 ………………………………….            ………………………
                                                                  .

          (ii) ………………………                ………………………………….            ………………………
                                                                  .

     (d) Penandatangan Cek
         (Signatories of Cheque)

          (i) ………………………

          (ii) ………………………

          (iii) ………………………

     (e) Penyertaan Ekuiti/Modal Berbayar
         (Equity/Paid-up Capital Participation)




                                                                                   3
           (i) Bumiputera            RM ……………………….

           (ii) Bukan Bumiputera     RM ....…………………….
               (Non-Bumiputera)

           (iii) Bukan Warganegara   RM ....…………………….
                 Malaysia
                 (Not Malaysian
           Citizen)


3.   BUTIR-BUTIR PENGARAH DAN PEMEGANG SAHAM
     (PARTICULARS OF DIRECTORS AND SHAREHOLDERS)

     (a)     Pengarah Dan Saham Yang Dipegang
             (Directors And Their Shareholdings)

                                                                                Saham
                                       No. KP/No. Pasport
             Nama Dan Alamat                                Warganegara        (Shares)
                                      (NRIC No.I Passport
            (Name And Address)                              (Citizenship)   Jumlah
                                              No.)                                    %
                                                                            (Total)




     (b)     Pemegang Saham
             (Shareholders)

                                                                                Saham
                                       No. KP/No. Pasport
             Nama Dan Alamat                                Warganegara        (Shares)
                                      (NRIC No.I Passport
            (Name And Address)                              (Citizenship)   Jumlah
                                              No.)                                    %
                                                                            (Total)




                                                                                  4
4.   BUTIR-BUTIR PENGURUSAN
     (PARTICULARS OF MANAGEMENT)

     (a)       Struktur Pekerjaan Sekarang
               (Present Employment Structure)

                                                                                          Bukan
                    Kategori Kerja                                                                                     Asing            Jumlah
                                                               Bumiputera               Bumiputera
                    (Job Category)                                                                                   (Foreign)          (Total)
                                                                                     (Non-Bumiputera)

      (a) Pengurusan
          (Management)

           (i) Profesional
               (Professional)
           (ii) Pentadbiran
                (Administration)

      (b) Eksekutif
          (Executive)

           (i) Teknikal
               (Technical)
           (ii) Pentadbiran
                (Administration)

      (c) Pekerja Mahir
          (Skilled Wokers)

      (d) Perkeranian
          (Clerical)

      (e) Pekerja Am/Lain-Lain
          (General Worker/Others)

           Jumlah (Total)

     (b)       Kakitangan Pengurusan
               (Management Staff)

       Nama                                                    Jawatan                               Warganegara               No. KP/
       (Name)                                                  (Position)                            (Citizenship)             No. Pasport
                                                                                                                               (NRIC No. I
                                                                                                                               Passport No.)
       (i)                                                     ...................................   .......................   ..........................
       .....................................................
       (ii)                                                    ...................................   .......................   ..........................


                                                                                                                                       5
        .....................................................
        (iii)                                                    ...................................   .......................    ..........................
        ....................................................
        (iv)                                                     ...................................   .......................    ..........................
        ....................................................
        (v)                                                      ...................................   .......................    ..........................
        .....................................................
        (vi)                                                     ...................................   .......................    ..........................
        .....................................................
        (vii)                                                    ...................................   .......................    ..........................
        ...................................................
        (viii)                                                   ...................................   .......................    ..........................
        ....................................................
        (ix)                                                     ...................................   .......................    ..........................
        .....................................................
        (x)                                                      ...................................   .......................    ..........................
        ......................................................



(c)   Carta Organisasi
      (Organization Chart)




5.    BUTIR-BUTIR PERBADANAN BERKAITAN DALAM PERNIAGAAN
      JUALAN LANGSUNG
      (PARTICULARS OF RELATED CORPORATIONS IN DIRECT                                                                             SALES
      BUSINESS)

                                     Alamat Surat-
                                                                                                                                   Perniagaan
                                     menyurat, No.
                                                                  No. Pendaftaran                                                  Utama dan
                                   Telefaks dan No.                                                   Tarikh
        Nama Syarikat                                                 Syarikat                                                   Bidang Operasi
                                        Telefon                                                    Pendaftaran
          (Name of                                                 (Company’s                                                       (Principal
                                   (Correspondence                                                   (Date of
         Company)                                                  Registration                                                   Business and
                                   Address, Telefax                                                Registration)
                                                                       No.)                                                          Field of
                                    and Telephone
                                                                                                                                   Operations)
                                         Nos.)




                                                                                                                                          6
                Bagi setiap syarikat yang disenaraikan di atas, sila berikan butir-butir mengikut
butiran 2a,            2b, 2c, 2d, 2e dan 3.
                (For every company listed above, please provide details in accordance with
items 2a, 2b,                  2c, 2d, 2e and 3).


6.     BUTIR-BUTIR PERNIAGAAN
       (PARTICULARS OF BUSINESS)

       (a)      Jenis Barang/Perkhidmatan yang Dipasarkan
                (Type of Goods/Services Marketed)

                Bahan Kosmetik                                 Barang/Kelengkapan Sukan
                (Cosmetics)                                    (Sport Goodsl Equipment)

                Vitamin/Makanan                                Perkakas Elektrik Rumah
                Tambahan/Makanan                               (Household Electrical Goods)
                Kesihatan
                (Vitamin/Food
                Supplements/
                Health Food)

                Barang-barang Kemas,                           Alat Penapis Air
                Jam Tangan dan Barang                          (Water Purifiers)
                Kemas Kostum
                (Jewellery, Watchers
                and Costume Jewellery)

                Pakaian/Bahan Tenunan                          Pinggan Mangkuk dan
                (Clothings/ Woven                              Peralatan Dapur
                Material)                                      (Crockery and Household
                                                               Goods)

                Ensaiklopedia/Buku                           Skim Percutian
                (Encyclopaedia/Books)                  Pengongsian Masa
                                                             (Time-sharing
                                                             Vacation Schemes)

                Barang Permainan                               Lain-lain
                (Toys)                                         (Others)

                (Jika lain-lain, berikan perincian)
                (If others, provide details)




                                                                                                7
       .....................................................................................................................

       .....................................................................................................................

       (Sila sertakan brosur/katalog/buku/maklumat termasuk harga
       barang/perkhidmatan yang dipasrkan).
       (Attach brochures/catalogues/books/information including prices of
goods/services marketed).



(b)    Skim Pemasaran dan Perdagangan
       (Marketing and Trading Scheme)

       (i)         Pemasaran barang/perkhidmatan dikendalikan secara:
                   (The marketing of goods/services takes the form of):

                   Pemasaran Satu Tingkat
                   (Single Level Marketing)

                   Pemasaran Berbilang Tingkat
                   (Multi Level Marketing)

                   Jualan Pesanan Pos
                   (Mail Order Sales)

                   Lain-lain
                   (Others)

       (ii)        Sila beri maklumat lengkap mengenai skim pemasaran dan
                   perdagangan dan carta-carta yang menunjukkan komisen-
                   komisen/bonus-bonus yang diberikan pada semua tingkat rancangan
                   jualan.
                   (Please provide complete information on marketing and trading
                   schemes and charts showing commissions/bonuses given at all levels
                   of the sales plan).

                   ..........................................................................................................

                   ..........................................................................................................

                   ..........................................................................................................

                   ..........................................................................................................

                   ..........................................................................................................

       (iii)       Adakah syarikat tuan mengamalkan kod etika perniagaan)
                   (Is your company practising any business code of ethics?)

                   Ya                                                           Tidak
                   (Yes)                                                        (No)

                   Jika “Ya”, sila kemukakan
                   (If “Yes”, please submit)


                                                                                                                                8
(c)   Butir-butir Lanjut Mengenai Skim Pemasaran dan Perdagangan
              (Additional Information on marketing and Trading Scheme)

             (i)     Fee kemasukan untuk Ya                            Tidak
                     menjadi pengedar/               (Yes)                        (No)
                     wakil jualan/ejen/
                     peraih/ahli
                     (Entrance fee to become
                     distributor/sales
                     representative/
                     agent/dealer/member)

                     Jika ”Ya,” nyatakan jumlah              RM .......................
                     (If ”Yes”, state the amount)

                     Adakah ini termasuk kit perniagaan/jualan?
                     (Does this include business/sales kit?)

                                                     Ya                           Tidak
                                                     (Yes)                        (No)

                     Jika “Tidak”, berapakah bayaran bagi kit perniagaan/jualan?
                     (If ”No”, what is the fee for business/sales kit?)

                                                             RM .......................

                     Jika “Ya”, nyatakan jumlah bagi kit perniagaan/jualan
                     (If ”Yes”, state the amount for the business/sales kit)

                                                             RM .......................

             (ii)    Adakah     komisen/bayaran     diberikan     untuk memperkenalkan
                     pengedar/wakil jualan/ejen/peraih/ahli baru?
                     (Are commissions/payment given for introducing new distributor/sales
                     representative/agent/dealer/member?)

                                                     Ya                           Tidak
                                                     (Yes)                        (No)

             (iii)   Nyatakan fee lain yang dikenakan untuk menjadi pengeadr/wakil
                     jualan/ejen/peraih/ahli:
                     (State     other     fees    to   become a     distributor/sales
                     representative/agent/dealer/member):

                     Pembelian stok/inventori                          RM ............................
                     (Purchase of stock/
                     inventory)




                     Fee latihan                                       RM ............................
                     (Training fee)




                                                                                                         9
                        Lain-lain fee                                                             RM ............................
                        (Other fees)

                        Beri maklumat terperinci mengenai bayaran lain
                        (Provide information in detail on other payments)

                        ..........................................................................................................

                        ..........................................................................................................

                        ..........................................................................................................

                        ..........................................................................................................


     (d)    Syarat-syarat lain yang dikenakan untuk menjadi pengedar/wakil
            jualan/ejen/peraih/ahli
            (Other conditions imposed to become a distributor/sales representative/
            agent/dealer/member)

            .....................................................................................................................

            .....................................................................................................................

            .....................................................................................................................

7.   LAIN-LAIN
     (OTHERS)

     (a)    Namakan Persatuan/Pertubuhan Berdaftar yang anda menjadi anggota di
     dalam dan luar negeri
            (Name the Registered Associations/Organizations of which you are a member,
            both inside and outside the country)

            Nama dan Alamat                                              Kaitan/Hubungan
            (name and Address)                                           (Association/Relationship)

            ...................................................          ..........................................................

            ...................................................          ..........................................................

            ...................................................          ..........................................................




                                                                                                                                      10
8.   PERAKUAN

     Saya/Kami dengan ini mengemukakan dokumen-dokumen yang berikut:
     (I/We hereby submit the following documents):

     (i)      Memorandum dan Perkara-Perkara Persatuan (yang ditentusahkan melalui
              akuan berkanun oleh seorang pengarah);
              (Memorandum and Articles of Association (verified by a statutory declaration
              made by a director));

     (ii)     Sijil Perbadanan, Borang 8 atau 9 (mana-mana yang berkenaan), Peraturan-
              Peraturan Syarikat 1966;
              (Certificate of Incorporation, Form 8 or 9 (whichever is applicable),
              Companies);

     (iii)    Borang 24 dan 49, Peraturan-Peraturan Syarikat 1966, yang diperakui oleh
              Pendaftar Syarikat;
              (Form 24 and 49, Companies Regulations 1966, certified by the Registrar of
              Companies);

     (iv)     Borang Penyata Tahunan suatu Syarikat Yang Mempunyai Modal Syer
              (menurut seksyen 165, Akta Syarikat 1965);
              (Form of Annual Return of a Company Having a share Capital (pursuant to
              section 165, Companies Act 1965));

     (v)      Kunci kira-kira teraudit dan akaun untukng rugi yang terbaru;
              (Latest audited balance sheet and profit and loss account);

     (vi)     Skim Pemasaran dan Perdagangan Syarikat;
              (Company’s Marketing and Trading Scheme);

     (vii)    Carta organisasi syarikat beserta nama-nama kakitangan yang memegang
              jawatan-jawatan penting;
              (Company’s organization chart together with the names and positions of key
              personnel);

     (viii)   Penyata terbaru caruman syarikat yang dikeluarkan oleh Kumpulan Wang
              Simpanan Pekerja (KWSP);
              (Latest statement of company’s contribution issued by the Employees
              Provident Fund (EPF));

     (ix)     Salinan terperaku surat Perjanjian/Perlantikan dengan Syarikat Utama jika
              berkaitan;
              (Certified copies of Agreement/Appointment letter with Principal Company if
              applicable);

     (x)      Brosur-brosur syarikat mengenai barang/perkhidmatan yang dipasarkan;
              (Company’s brochures on goods/services marketed);

     (xi)     Kod etika perniagaan;
              (Business code of ethics);

     (xii)    Dokumen lain yang berkaitan dengan bidang perniagaan seperti pendaftaran
              dengan SIRIM, Biro Pengawalan Farmaseutikal Kebangsaan dan lain-lain.




                                                                                       11
                   (Other documents relevant to the business such as registration with SIRIM,
                   National Pharmaceutical Control Bureau, etc.).



9.     PERISYTIHARAN
       (DECLARATION)

        Saya/Kami dengan ini mengaku segala maklumat di dalam Borang ini dan mana-
        mana lampiran adalah benar dan tepat.
        Saya/Kami faham bahawa apa-apa pernyataan palsu yang dibuat di dalam Borang
ini hendaklah menjadi suatu kesalahan di bawah Akta.
        (I/We hereby declare that all information in this Form and any annexure(s) are true and
        accurate. I/We understand that any false statements made in this Form shall be an
        offence under the Act).



       ....................................................                                      ...................................
            Tandatangan Pemohon                                                                         Tarikh (Date)
            (Signature of Applicant)


       Nama: .................................................................................
       (Name):

       No. KP/No. Pasport: ...........................................................
       (NRIC No./Passport No.):


       Jawatan dalam Syarikat: .....................................................
       (Position in Company):


                                                                                                      ................................
                                                                                                      Meterai Syarikat
                                                                                                     (Company’s Seal)

       NOTA: Mengikut seksyen 5 Akta Jualan Langsung 1993 Pengawal boleh meminta
       apa-apa maklumat atau dokumen lain yang dinyatakan olehnya dan boleh meminta
       maklumat atau dokumen yang berbeza daripada pemohon yang berlainan, atau
              pemohon daripada golongan, kategori atau perihal yang berlainan.

       NOTE: According to section 5 of the Direct Sales Act 1993 the Controller may request
       for such other information or documents as may be specified by him, and may request
       different information or documents from different applicants, or different classes,
       categories or descriptions of applicants.




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