GENERAL INFORMATION

COMPANY NAME :

ADDRESS :

BILLING ADDRESS :
(If different from above)

TELEPHONE NO. : FAX. NO. :

E-MAIL :
REGISTERATION NO.

TYPE OF ORGANIZATION
LTD COMPANY - SHAREHOLDERS:
DATE ESTABLISHED:
PARTNERSHIP - PARTNERS:
DATE ESTABLISHED:
SOLE TRADER - OWNER(S):
DATE ESTABLISHED:
OTHERS - PLEASE STATE:
DATE ESTABLISHED:

PRINCIPAL ACTIVITIES:
AUTHORISED CAPITAL: PAID-UP CAPITAL:
BANK NAME & BRANCH: ACCOUNT NO:

CONTACT INFORMATION
MANAGING DIRECTOR :
FINANCIAL CONTROLLER :
PAYMENT CONTACT :
TELEPHONE : FAX. NO.: E-MAIL:
 TRADE REFERENCES

NAME : DESIGNATION:
COMPANY :
TEL. NO :

NAME : DESIGNATION:
COMPANY :
TEL. NO :

I hereby agree to Enviroterm Sdn Bhd’s Standard Terms and Condition of Sale and certify that all information
provided is true and correct. I also understand that the Supplier will rely on the accuracy of this information for
any credit that may be granted. Any falsified information provided will disqualify this application.

Signature Co. Chop

Name: Designation:
Date:

Please attach the following documents for the processing of your application:

1) Latest Form 24 & 49

2) Latest Audited Account
3) Latest Bank Statement ( 1 month)

FOR APPROVAL

Credit Limit: _________________ Credit Terms: _____

REMARK: ___ ___________

___________

Approval By: Date

Position: