/ UNIVERSITI TENAGA NASIONAL
Jalan IKRAM-UNITEN, 43000 Kajang Selangor /
Form: UNITEN/SMARTUNIVERCITY/003-1
CALL FOR STRATEGIC PARTNERSHIP CHECKLIST

Submission of form must be accompanied by the following documents. Pleasetick (√)as a checklist and email it to before 16th Oct 2017.

For Strategic Research Funder:

Call for Strategic Partnership Checklist*

Call for Strategic Partnership Form (Section A only)*

Company’s Profile*

Proposal for Funding Model*

For Technical Advisory Panel:

Call for Strategic Partnership Checklist*

Call for Strategic Partnership Form (Section B only)*

Curriculum Vitae/Resume (if no URL to LinkedIn or personal website)*

*mandatory

PARTICIPATION SUBMISSION ACCEPTING SLIP

UNITEN Smart UniverCityrecommendsthat theparticipation interestsubmittedis complete andcomplies withall conditionsset forthefurther processingby theUNITEN Smart UniverCityAdministrative Unit.Should any inquiry is required to put forward,the receiptslipsshould beused as a referencein order to facilitatea quick review byUNITEN.

(To be filled by UNITEN Smart UniverCity Administrative Unit)

Reference Number: ...... Date ......

/ UNIVERSITI TENAGA NASIONAL
Jalan IKRAM-UNITEN, 43000 Kajang Selangor /
Form: UNITEN/SMARTUNIVERCITY/002-1
CALL FOR STRATEGIC PARTNERSHIP FORM

SECTION A

(To be completed by potential strategic Research Funder)

COMPANY PARTICULARS
Name of Company:
Full Address of the Company:
Type of Company:
Multi-National
Private
Government
Agency
Public
NGO
Other:
Nature of Business:
Manufacturing
Supply Chain
Energy
Water
Retail
Transportation
Healthcare
Oil & Gas
Construction
Logistics
Agriculture
Facilities
R&D
Others:
Name of Representative from the Company:
Telephone (Office):
Telephone (Mobile)
Email:
I hereby proclaim that all information given as stated above is accurate and true. I understand that any inaccurate or false information or omission of material information will render this application invalid and that, if appointed as a Strategic Partner for UNITEN Smart UniverCity on the basis of such information, our participation can be terminated and we can also be subjected to any penalty in the agreement.
Name :
Signature : Date :
/ UNIVERSITI TENAGA NASIONAL
Jalan IKRAM-UNITEN, 43000 Kajang Selangor /
Form: UNITEN/SMARTUNIVERCITY/002-1
CALL FOR STRATEGIC PARTNERSHIP FORM

SECTION B

(To be completed by the potential Technical Advisory Panel)

EXPERT PARTICULARS
Name of the Company:
Full Address of the Company:
Name of Technical Advisor:
Telephone Number (Office):
Telephone Number (Mobile):
URL for LinkedIn or personal website:
Area of Expertise:
Proposed contribution as UNITEN Smart UniverCity Technical Advisory Panel:
1.
2.
3.
Requirement (if any):



I hereby proclaim that all information given as stated above is accurate and true. I understand that any inaccurate or false information or omission of material information will render this application invalid and that, if appointed as a Strategic Partner for UNITEN Smart UniverCity on the basis of such information, our participation can be terminated and we can also be subjected to any penalty in the agreement.
Name :
Signature : Date :

SECTION C

(To be completed by UNITEN Smart UniverCity Administrative Unit)

UNITEN SMART UNIVERCITY TASK FORCE
RECOMMENDED / NOT RECOMMENDED
Comment : ______
______
______
Signature :
Name : Date :

SECTION D

UNITEN SMART UNIVERCITY ADVISOR
RECOMMENDED / NOT RECOMMENDED
Comment : ______
______
Signature :
Name : Date :

SECTION E

VICE CHANCELLOR UNIVERSITI TENAGA NASIONAL
APPROVED / NOT APPROVED
Comment : ______
______
Signature :
Name : Date :