P.U.(A) 129/2000
COMMUNICATIONS AND MULTIMEDIA (LICENSING) REGULATIONS 2000
THIRD SCHEDULE
THIRD SCHEDULE
(Subperaturan 6(1)/Subregulations 6(1))
BORANG A/FORM A
AKTA KOMUNIKASI DAN MULTIMEDIA 1998/
COMMUNICATIONS AND MULTIMEDIA ACT 1998
PERATURAN-PERATURAN KOMUNIKASI DAN MULTIMEDIA (PELESENAN)
2000/
COMMUNICATIONS AND MULTIMEDIA (LICENSING) REGULATIONS 2000
PERMOHONAN UNTUK LESEN INDIVIDU/
APPLICATION FOR INDIVIDUAL LICENCE
__________________
Tandakan (_/ ) mana-mana yang berkenaan
Tick (_/ ) whichever is applicable
1. Permohonan untuk*
Application for*
(a) lesen kemudahan rangkaian ________
network facilities licence
(b) lesen perkhidmatan rangkaian ________
network service licence
(c) [Deleted P.U.(A) 144/2005]
(d) lesen perkhidmatan aplikasi kandungan ________
content applications service licence
2. Jenis permohonan
Type of application
(a) permohonan baru ________
new application
(b) pembaharuan ________
renewal
*Nota: Permohonan untuk dua lesen atau lebih hendaklah dibuat dalam borang permohonan yang berasingan, setiap satunya disokong dengan maklumat yang berkaitan.
*Note: An application for two or more licences shall be made in separate application forms, each supported by the relevant information.
_____________________
A. BUTIR-BUTIR PEMOHON
PARTICULARS OF APPLICANT
_____________________
1. Nama pemohon dan No. Syarikat
Name of applicant and Company No.
................................
................................
................................
................................
2. Pejabat berdaftar
Registered office
................................
................................
................................
................................
No. Telefon ................................
Telephone No.
No. Faks ................................
Fax No.
Alamat e-mel ................................
E-mail address
3. Tempat perniagaan utama
Principal place of business
................................
................................
................................
................................
No. Telefon................................
Telephone No.
No. Faks................................
Fax No.
Alamat e-mel........................................................
E-mail address
4. Butir-butir pemegangan saham pemohon*
Particulars of shareholding of the applicant*
Nama
Name | No. KPPN/
No. Pasport/
No. Syarikat
NRIC No./
Passport No./
Company No. | Alamat
Address | Jumlah dan % saham
Yang dipegang
Number and % of
Shares held |
*Sila nyatakan pemegang saham benefisial terakhir.
*Please indicate ultimate beneficial shareholder.
5. Adakah pemohon kini memegang apa-apa penguntukan spektrum, penguntukan radas atau penguntukan kelas?
Does the applicant currently hold a spectrum assignment, apparatus assignment or a class assignment?
[ ] Ya/Yes [ ] Tidak/No
Jika ya, sila berikan butir-butir
If yes, please provide particulars
...........................................
...........................................
...........................................
...........................................
Jika tidak, adakah pemohon telah membuat permohonan sedemikian?
If no, has the applicant made such an application?
[ ] Ya/Yes [ ] Tidak/No
Jika ya, sila berikan butir-butir
If yes, please provide particulars
...........................................
...........................................
...........................................
...........................................
6. Adakah pemohon telah diuntukkan apa-apa nombor atau apa-apa alamat elektronik?
Has the applicant been assigned any numbers or any electronic addresses?
[ ] Ya/Yes [ ] Tidak/No
Jika ya, sila berikan butir-butir
If yes, please provide particulars
...........................................
...........................................
...........................................
...........................................
Jika tidak, adakah pemohon telah membuat permohonan sedemikian?
If no, has the applicant made such an application?
[ ] Ya/Yes [ ] Tidak/No
Jika ya, sila berikan butir-butir
If yes, please provide particulars
...........................................
...........................................
...........................................
...........................................
7. Adakah pemohon membuat apa-apa usaha sama?
Has the applicant entered into any joint ventures?
[ ] Ya/Yes [ ] Tidak/No
Jika ya, sila berikan butir-butir termasuk butir-butir pematuhan dengan kehendak Jawatankuasa Pelaburan Asing, jika ada
If yes, please provide particulars, including particulars of compliance with the Foreign Investment Committee requirements, if any
...........................................
...........................................
...........................................
...........................................
8. (a) Pernahkah pemohon diberikan lesen di bawah Akta Telekomunikasi 1950?
Has the applicant been licensed under the Telecommunications Act 1950?
[ ] Ya/Yes [ ] Tidak/No
(b) Pernahkah pemohon diberikan lesen di bawah Akta Penyiaran 1988?
Has the applicant been licensed under the Broadcasting Act 1988?
[ ] Ya/Yes [ ] Tidak/No
Jika ya, sila berikan butir-butir
If yes, please provide particulars
...........................................
...........................................
...........................................
...........................................
9. Adakah lesen pemohon di bawah subperenggan 8(a) atau (b) pernah digantung atau dibatalkan?
Was the applicant's licence under subparagraph 8(a) or (b) ever suspended or revoked?
[ ] Ya/Yes [ ] Tidak/No
Jika ya, sila berikan butir-butir
If yes, please provide particulars
...........................................
...........................................
...........................................
...........................................
B. PENGAKUAN
DECLARATION
1. Adakah penerima, atau penerima dan pengurus, pernah Ya/Tidak
dilantik berkenaan dengan apa-apa harta pemohon?
Has a receiver, or receiver and manager, been Yes/No
appointed in respect of any of the applicant's
assets?
2. Adakah pemohon telah mencapai kata sepakat Ya/Tidak
atau membuat perkiraan dengan pemiutang?
Has the applicant entered into a compromise or Yes/No
arrangement with creditors?
3. Adakah petisyen telah dikemukakan ke mahkamah Ya/Tidak
untuk menggulungkan pemohon?
Has a petition been presented in court for the Yes/No
winding up of the applicant?
C. MAKLUMAT
INFORMATION
1. Maklumat dua orang iaitu dua pengarah atau seorang pengarah dan setiausaha syarikat pemohon yang boleh dihubungi untuk maklumat lanjut:
Particulars of two persons namely two directors or a director and the company secretary of the applicant who may be contacted for further information:
Nama
Name | Jawatan
Position | No. Telefon
Telephone No. | Alamat
Address |
|  | | |
2. Apa-apa maklumat tambahan yang dianggap berkaitan dengan permohonan ini:
Any additional information considered relevant to this application:
......................................
......................................
......................................
......................................
Kami, .................................................... pemohon, dengan ini mengaku dan mengesahkan bahawa kami layak memohon untuk mendapatkan lesen individu di bawah Akta dan semua maklumat yang diberikan dalam permohonan ini dan dalam lampiran yang dikepilkan adalah benar dan tepat.
We, .......................................................... the applicant, declare and confirm that we are eligible to apply for an individual licence under the Act and that all the information given in this application and in the attached annexes is true and accurate.
Tarikh:
Date:
Ditandatangani oleh .....................................................]
Signed by .....................................................................]
untuk dan bagi pihak ...................................................]
for and on behalf of ....................................................]
NOTA:
NOTE:
Jika ruang yang disediakan tidak mencukupi untuk memberikan butir-butir, sila kepilkan lampiran. Setiap lampiran mestilah ditandatangani ringkas oleh orang yang menandatangani permohonan ini.
If the space is insufficient to provide the particulars, please attach annexes. Any annex should be initialled by the signatory to this application.
(Peraturan 10/Regulation 10)
BORANG B/FORM B
AKTA KOMUNIKASI DAN MULTIMEDIA 1998/
COMMUNICATIONS AND MULTIMEDIA ACT 1998
PERATURAN-PERATURAN KOMUNIKASI DAN MULTIMEDIA
(PELESENAN) 2000/
COMMUNICATIONS AND MULTIMEDIA (LICENSING) REGULATIONS 2000
LESEN INDIVIDU/
INDIVIDUAL LICENCE
ASAL
ORIGINAL
No. Siri:
Serial No.: | No. Lesen:
Licence No.: |
MENURUT SEKSYEN 30 DAN 126/205*
AKTA KOMUNIKASI DAN MULTIMEDIA 1998
PURSUANT TO SECTIONS 30 AND 126/205* OF THE
COMMUNICATIONS AND MULTIMEDIA ACT 1998
Lesen adalah diberi kepada ...................................
A licence is granted to
untuk ...................................
to
mempunyai atau memberikan apa-apa kemudahan rangkaian*
own or provide any network facilities*
memberikan apa-apa perkhidmatan rangkaian*
provide any network services*
memberikan apa-apa perkhidmatan aplikasi*
provide any application services*
memberikan apa-apa perkhidmatan aplikasi kandungan*
provide any content applications service*
| berkuat kuasa dari ............... | sehingga ................. |
| with effect from | until |
[Am. P.U.(A) 298/2001]
tertakluk kepada syarat-syarat yang berikut:
subject to the following conditions:
The following standard licence conditions:
Tafsiran/ Interpretation
[Ins. P.U.(A) 298/2001]
(a) Syarat-syarat standard yang berikut:
The following standard licence conditions:
...................................
...................................
...................................
(b) Syarat-syarat khas atau tambahan yang berikut:
The following special or additional licence conditions:
...................................
...................................
...................................
Bertarikh ...................................
Dated
...................................
Menteri Tenaga, Komunikasi dan Multimedia
Minister of Energy, Communications and Multimedia
*Potong mana-mana yang tidak berkenaan.
*Delete whichever is not applicable.
THIRD SCHEDULE
(Peraturan 24 dan 28/Regulations 24 and 28)
BORANG C1/FORM C1
AKTA KOMUNIKASI DAN MULTIMEDIA 1998/
COMMUNICATIONS AND MULTIMEDIA ACT 1998
PERATURAN-PERATURAN KOMUNIKASI DAN MULTIMEDIA
(PELESENAN) 2000/
COMMUNICATIONS AND MULTIMEDIA (LICENSING) REGULATIONS 2000
LESEN KELAS/
CLASS LICENCE
ASAL
ORIGINAL
No. Siri:
Serial No.: | No. Lesen:
Licence No.: |
MENURUT SEKSYEN 44 DAN 126
AKTA KOMUNIKASI DAN MULTIMEDIA 1998
PURSUANT TO SECTIONS 44 AND 126 OF THE
COMMUNICATIONS AND MULTIMEDIA ACT 1998
Lesen adalah diberi berkenaan dengan
A licence is granted in respect of
Pemunyaan atau pemberian apa-apa kemudahan rangkaian
The ownership or provision of any network facilities
yang butir-butirnya adalah seperti berikut:
the particulars of which are as follows:
.........................................
.........................................
.........................................
.........................................
.........................................
berkuat kuasa mulai .........................................
with effect from
tertakluk kepada syarat-syarat standard yang berikut dan apa-apa syarat standard lain sebagaimana yang diisytiharkan oleh Menteri dari masa ke masa:
subject to the following standard conditions and such other standard conditions as may be declared by the Minister from time to time:
.........................................
.........................................
.........................................
.........................................
Bertarikh ................................................
Dated
.........................................
Menteri Tenaga, Komunikasi dan Multimedia
Minister of Energy, Communications and Multimedia
THIRD SCHEDULE
(Peraturan 24 dan 29/Regulations 24 and 29)
BORANG C2/FORM C2
AKTA KOMUNIKASI DAN MULTIMEDIA 1998/
COMMUNICATIONS AND MULTIMEDIA ACT 1998
PERATURAN-PERATURAN KOMUNIKASI DAN MULTIMEDIA
(PELESENAN) 2000/
COMMUNICATIONS AND MULTIMEDIA (LICENSING) REGULATIONS 2000
LESEN KELAS/
CLASS LICENCE
ASAL
ORIGINAL
No. Siri:
Serial No.: | No. Lesen:
Licence No.: |
MENURUT SEKSYEN 44 DAN 126
AKTA KOMUNIKASI DAN MULTIMEDIA 1998
PURSUANT TO SECTIONS 44 AND 126 OF THE
COMMUNICATIONS AND MULTIMEDIA ACT 1998
Lesen adalah diberi berkenaan dengan
A licence is granted in respect of
Pemberian apa-apa perkhidmatan rangkaian
The provision of any network services
yang butir-butirnya adalah seperti berikut:
the particulars of which are as follows:
.........................................
.........................................
.........................................
.........................................
berkuat kuasa mulai ..................................
with effect from
tertakluk kepada syarat-syarat standard yang berikut dan apa-apa syarat standard lain sebagaimana yang diisytiharkan oleh Menteri dari masa ke masa:
subject to the following standard conditions and such other standard conditions as may be declared by the Minister from time to time:
.........................................
.........................................
.........................................
.........................................
.........................................
Bertarikh ......................................................
Dated
.........................................
Menteri Tenaga, Komunikasi dan Multimedia
Minister of Energy, Communications and Multimedia
THIRD SCHEDULE
(Peraturan 24 dan 30/Regulations 24 and 30)
BORANG C3/FORM C3
AKTA KOMUNIKASI DAN MULTIMEDIA 1998/
COMMUNICATIONS AND MULTIMEDIA ACT 1998
PERATURAN-PERATURAN KOMUNIKASI DAN MULTIMEDIA
(PELESENAN) 2000/
COMMUNICATIONS AND MULTIMEDIA (LICENSING) REGULATIONS 2000
LESEN KELAS/
CLASS LICENCE
ASAL
ORIGINAL
No. Siri:
Serial No.: | No. Lesen:
Licence No.: |
MENURUT SEKSYEN 44 DAN 126
AKTA KOMUNIKASI DAN MULTIMEDIA 1998
PURSUANT TO SECTIONS 44 AND 126 OF THE
COMMUNICATIONS AND MULTIMEDIA ACT 1998
Lesen adalah diberi berkenaan dengan
A licence is granted in respect of
Pemberian apa-apa perkhidmatan aplikasi
The provision of any applications services
yang butir-butirnya adalah seperti berikut:
the particulars of which are as follows:
........................................
........................................
........................................
........................................
berkuat kuasa mulai ..........................................
with effect from
tertakluk kepada syarat-syarat standard yang berikut dan apa-apa syarat standard lain sebagaimana yang diisytiharkan oleh Menteri dari masa ke masa:
subject to the following standard conditions and such other standard conditions as may be declared by the Minister from time to time:
........................................
........................................
........................................
........................................
Bertarikh ......................................................
Dated
........................................
Menteri Tenaga, Komunikasi dan Multimedia
Minister of Energy, Communications and Multimedia
THIRD SCHEDULE
(Peraturan 24 dan 31/Regulations 24 and 31)
BORANG C4/FORM C4
AKTA KOMUNIKASI DAN MULTIMEDIA 1998/
COMMUNICATIONS AND MULTIMEDIA ACT 1998
PERATURAN-PERATURAN KOMUNIKASI DAN MULTIMEDIA
(PELESENAN) 2000/
COMMUNICATIONS AND MULTIMEDIA (LICENSING) REGULATIONS 2000
LESEN KELAS/
CLASS LICENCE
ASAL
ORIGINAL
No. Siri:
Serial No.: | No. Lesen:
Licence No.: |
MENURUT SEKSYEN 44 DAN 126/205*
AKTA KOMUNIKASI DAN MULTIMEDIA 1998
PURSUANT TO SECTIONS 44 AND 126/205* OF THE
COMMUNICATIONS AND MULTIMEDIA ACT 1998
Lesen adalah diberi berkenaan dengan
A licence is granted in respect of
Pemberian apa-apa perkhidmatan aplikasi kandungan
The provision of any content applications services
yang butir-butirnya adalah seperti berikut:
the particulars of which are as follows:
........................................
........................................
........................................
........................................
berkuat kuasa mulai ..........................................
with effect from
tertakluk kepada syarat-syarat standard yang berikut dan apa-apa syarat standard lain sebagaimana yang diisytiharkan oleh Menteri dari masa ke masa:
subject to the following standard conditions and such other standard conditions as may be declared by the Minister from time to time:
........................................
........................................
........................................
........................................
Bertarikh ......................................................
Dated
........................................
Menteri Tenaga, Komunikasi dan Multimedia
Minister of Energy, Communications and Multimedia
* Potong mana-mana yang tidak berkenaan.
* Delete whichever is not applicable.
THIRD SCHEDULE
(Subperaturan 25(1)/Subregulation 25(1))
BORANG D/FORM D
AKTA KOMUNIKASI DAN MULTIMEDIA 1998/
COMMUNICATIONS AND MULTIMEDIA ACT 1998
PERATURAN-PERATURAN KOMUNIKASI DAN MULTIMEDIA
(PELESENAN) 2000/
COMMUNICATIONS AND MULTIMEDIA (LICENSING) REGULATIONS 2000
NOTIS PENDAFTARAN UNTUK LESEN KELAS/
REGISTRATION NOTICE FOR CLASS LICENCE
ASAL
ORIGINAL
No. Siri:
Serial No:
1. NO. LESEN KELAS ..................................
CLASS LICENCE NO.
(a) lesen kemudahan rangkaian___________
network facilities licence
(b) lesen perkhidmatan rangkaian___________
network service licence
(c) lesen perkhidmatan aplikasi___________
applications service licence
(d) lesen perkhidmatan aplikasi kandungan___________
content applications service licence
Tandakan (_/) lesen kelas yang dengannya pemohon berhasrat untuk menjalankan kendalian:
Tick (_/) the class licence the applicant wishes to operate under:
2. (a) Nama Pemohon
Name of Applicant
..........................................
(b ) Kedudukan pemohon di sisi undang-undang
Legal status of applicant
| [ ] Syarikat/Company | [ ] Perkongsian/Partnership |
| [ ] Individu/Individual | [ ] Persatuan/Society |
| [ ] Lain-lain/Others* | |
* Sila nyatakan dan berikan butir-butir dalam lampiran
* Please specify and provide particulars in annex
(c) Alamat/Address
.........................................
.........................................
.........................................
.........................................
| No. Telefon ................................ | No. Faks ................................. |
| Telephone No. | Fax No. |
Alamat e-mel .............................
E-mail address
3. Perihalan am kemudahan/perkhidmatan/aktiviti yang akan dipunyai atau diberi atau dikendalikan oleh pemohon:
General description of facilities/service/activity to be owned or provided or operated by the applicant:
....................................................
.....................................................
......................................................
4. Kemudahan/perkhidmatan terletak/akan diberikan di (sila berikan pengenalpastian spt. Protokol Internet/alamat laman web, jika terpakai):
The facilities/services are located/provided at (please provide on-line identification e.g. Internet Protocol/web site address, where applicable):
.....................................................
....................................................
.....................................................
| No. Telefon ................................ | No. Faks ................................. |
| Telephone No. | Fax No. |
Alamat e-mel .............................
E-mail address
5. Saya/Kami, ................................................ pemohon, dengan ini mengaku dan mengesahkan bahawa semua maklumat yang diberikan dalam permohonan ini dan apa-apa lampiran yang dikepilkan adalah benar dan tepat.
I/We, ............................................................. the applicant, declare and confirm that all the information given in this application and in the attached annexes is true and accurate.
Tarikh: ...................................................
Date:
Ditandatangani oleh .....................................................]
Signed by .....................................................................]
untuk dan bagi pihak ...................................................]
for and on behalf of ....................................................]
NOTA:
NOTE:
Jika ruang yang disediakan tidak mencukupi untuk memberikan butir-butir, sila kepilkan lampiran. Setiap lampiran mestilah ditandatangani ringkas oleh orang yang menandatangani permohonan ini.
If the space is insufficient to provide particulars, please attach annexes. Any annex should be initialled by the signatory to this application.
Made 31 March 2000.
[KTKM(S) 353/146/5 Klt. 4; PN(PU2)601]
DATUK AMAR LEO MOGGIE
Minister of Energy, Communications and Multimedia
