Filetype Excel XLS | Posted on 05 Jul 2022 | 3 years ago
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171x Filetype XLS File size 0.08 MB Source: www.miti.gov.my
Sheet 1: REGISTRATION GUIDELINE
| GUIDELINE FOR REGISTRATION | |
| 1 | This form is to be completed by both anchor company and participating companies for PPV FACTORY ON-SITE. |
| 2 | Anchor company must list down other participating companies in Form 2 and provide employees list in respective Annexes (by company). |
| 3 | If the anchor companies do not wish to submit details of the other participating companies, then the participating companies have to submit their employees list individually to MITI using Annex template but to clearly indicate the anchor company name in Form 2. |
| 4 | Please email the completed form together with the signed PIKAS Terms and Conditions to vaccine4industry@miti.gov.my. |
| PROGRAM IMUNISASI INDUSTRI COVID-19 KERJASAMA AWAM SWASTA (PIKAS) PUSAT PEMBERIAN VAKSIN (PPV) | ||||||||||||
| (FOR PPV FACTORY ON-SITE APPLICATION) | ||||||||||||
| Kindly indicate the location of the proposed PPV factory on-site: | ||||||||||||
| 1. ……………………(option 1)………...…….… | ||||||||||||
| 2. ……………………(option 2)…………………. | ||||||||||||
| 3. …………………..(option 3)………………….. | ||||||||||||
| NO. | COMPANY/ ORGANISATION/ AGENCY | COMPANY REGISTRATION NO. | ADDRESS | POSTCODE | STATE | BUSINESS ACTIVITY | CONTACT PERSON DETAILS | TOTAL EMPLOYEES (registered for vaccination) | NUMBER OF POSITIVE CASES (ACTIVE CASES AT THE TIME OF APPLICATION) | MANUFACTURING LICENSE / MIDA EXEMPTION LETTER/ PBT LICENSE REGISTRATION | ANNEX | |
| NAME | PHONE NO./ |
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| 1 | Company A (Anchor) | Annex 1 | ||||||||||
| 2 | Company B (Participating Company) | Annex 2 | ||||||||||
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| ANNEX 1 | |||||||||
| To be filled by the companies | |||||||||
| Company Location: ………………………………………………………………………. (e.g. Industrial Estate/ Industrial area/ industrial zone) | |||||||||
| Details of Company: (to be completed by company for their local and foreign employees already registered for COVID-19 Vaccination Programme) | |||||||||
| Company Name: …………………………………………………………………………….. | |||||||||
| Company Registration No.: ……………………………………………………………. | |||||||||
| Company Address | : …………………………………………………………………………….. | ||||||||
| ………………………………………………………………………………… | |||||||||
| Postcode | : …………………………………………………………………………………… | ||||||||
| Tel No. | : ……………………………………….. | ||||||||
| Contact person 1 | Name : …………...…………………………… | ||||||||
| Designation:………………………………….. | |||||||||
| H/P No.: ………………………………………. | |||||||||
| Email Address:………………………………. | |||||||||
| Contact person 2 | Name:………………………………………….. | ||||||||
| Designation: …………………………………… | |||||||||
| H/P No.:…………………………………………. | |||||||||
| Email address: …………………………………. | |||||||||
| Total head count registered under COVID-19 Vaccination Programme : …………………………. | |||||||||
| No. | Name | No. I/C or Passport No. | Employee ID | Company Name/ Kementerian | MySejahtera ID | Phone No. | Age | Gender | |
| Kindly indicate - | 1 (for male) | ||||||||
| 2 (for female) | |||||||||
| DISCLAIMER | |||||||||
| We hereby confirm that the information provided herein is accurate, correct and complete and that the documents submitted along with this application form are genuine. We undertake to inform the Ministry of International Trade and Industry (MITI) in writing (at vaccine4industry@miti.gov.my) of any changes to the information already provided and to update the information on this form whenever requested to do so by the MITI. We hereby declare that, in the event of our information in this form will be required to be shared with other Ministries and/or agencies for the purpose of this Immunisation Programme, we explicitly agree to MITI’s full compliance to provide such information without the need for MITI to notify us or to seek our additional consent. |
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