FORM 11

Version 2.0

Please fill in where applicable and tick (ü) where appropriate

Submission by applicant seeking approval / registration
Submission on behalf of the applicant (third party)

Authorised Signatory:

Name:

Designation & Department:

Date: Company Stamp

1. / PARTICULARS OF APPLICANT

Name of applicant

For resident:
Business registration/NRIC no.
For non-resident:
Passport no.
Nationality
Registered address
Correspondence address
(If different from above)
Contact person
Designation
Telephone no.
Facsimile no.
E-mail address
Principal business activity/occupation of applicant
(for company, base on information as contained in the audited account)
Basic Group
/
Individual
Sole Proprietor
Partnership
Professional Body (such as lawyers,
doctors, accountants who are not registered
with Suruhanjaya Syarikat Malaysia)
Company
For a resident company, please also indicate the controlling status:
Resident Controlled Company (RCC)
Non-Resident Controlled Company (NRCC)
Federal/General Government
(include embassies)
State Government
Local Government
Statutory Body
Trade Union
Co-operative
Society / Association
International Organisation
Foundation
Others
Details of third party (for application submitted on behalf of applicant)
Name of Company / Individual
Correspondence Address
Contact person
Designation
Telephone no.
Facsimile no.
E-mail address
2. / DETAILS OF OVERSEAS COUNTERPARTY
Name
Country & Town
Relationship with applicant
3. / DETAILS OF SALES REVENUE AND PRODUCTION
A. Gross revenue (Past 12 months):
(i) Sales in Malaysia (RM)
(ii) Sales outside Malaysia:
a)  For goods produced by applicant
b)  For goods produced by related companies (to be completed by an IPC only)
c)  For goods produced by others (to be completed by an IPC only) / Amount
(RM equivalent) / %
TOTAL
B.  Gross import (Past 12 months)
(i)  raw materials/intermediate goods
(ii)  others
TOTAL
C.  Cost of raw materials and intermediate goods
(i)  used for production of exported goods in A(ii) above:
(a)  sourced from Malaysia
(b)  sourced from outside Malaysia
(ii)  used for production for local sales
TOTAL
The currency for recording the offsetting arrangement
4. / Cost of imported material inputs used by related companies
for goods exported through the IPC
(This part is to be completed only by an IPC which is established as a separate entity in Malaysia)
Name of related company of the IPC group*
(Please provide organization chart and percentage of shareholding) / Cost of imported materials
5. / REASON(S) FOR THE OFFSETTING ARRANGEMENT

* Related company is :-

(a)  onshore parent of IPC; or

(b)  any onshore company in which the parent (irrespective onshore or offshore) or the IPC has at least 20% effective shareholding

6. / BACKGROUND, RATIONALE AND OTHER INFORMATION TO SUPPORT THE APPLICATION

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