P.U.(A) 359/98
DIGITAL SIGNATURE REGULATIONS 1998
FIRST SCHEDULE
(Regulation 3)
FORMS
 | Regulation | Form | Particulars |
| | | |
| 1. | Regulation 7, 12, 51, 54, 64 and 67 | Form 1 | Application for licence/ certificate of recognition and renewal of licence/ certificate of recognition |
| | | |
| 2. | Regulation 10 | Form 2 | Certification Authority Licence |
| | | |
| 3. | Regulation 13 | Form 3 | Application for duplicate licence |
| | | |
| 4. | Regulation 26 | Form 4 | Notice of Claim |
| | | |
| 5. | Regulation 54 and 67 | Form 5 | Certificate of recognition for repository/ date/ time stamp service |
BORANG 1 /FORM 1
[Peraturan 7, 12, 51, 54, 64 dan 67/
Regulations 7, 12, 51, 54, 64 dan 67]
AKTA TANDATANGAN DIGITAL 1997/
DIGITAL SIGNATURE ACT 1997
PERATURAN-PERATURAN TANDATANGAN DIGITAL 1998/
DIGITAL SIGNATURE REGULATIONS 1998
PERMOHONAN BAGI LESEN/PERAKUAN PENGIKTIRAFAN DAN
PEMBAHARUAN LESEN/PERAKUAN PENGIKTIRAFAN*
APPLICATION FOR LICENCE/CERTIFICATE OF RECOGNITION
AND RENEWAL OF LICENCE/CERTIFICATE OF RECOGNITION*
______________________________________________________
Tandakan (_/) di ruang yang berkenaan.
Tick (_/) whichever is relevant.
(a) Permohonan untuk
Application for
(i) Lesen
Licence : _________
(ii) Perakuan pengiktirafan bagi
Certificate of recognition for
(A) repositori
repository : _________
(B) perkhidmatan penanda tarikh/masa
date/time stamp service : _________
(b) Jenis permohonan
Type of application
(i) permohonan baru
new application
(A) peringkat penubuhan
establishment stage : _________
(B) peringkat pengendalian
operation stage : ________
(ii) pembaharuan
renewal : _________
________________________________________________
A. BUTIR-BUTIR PEMOHON
PARTICULAR OF APPLICANT
________________________________________________
1. Nama pemohon dan alamat surat-menyurat
Name of applicant and correspondence address
................................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
...............................................................................................................
No. telefon ..............................
Telephone no. | No. faks ................................
Fax no. | Orang untuk dihubungi ...............................................................
Contact person |
Alamat mel elektronik ............................................................
E-mail address
Jawatan ......................................................................
Designation
2. Nama pembezaan pemohon
Distinguished name of applicant
...................................................................................................................
...................................................................................................................
3. Tarikh diperbadankan/dibentuk .....................................................
Date of incorporation/formation
4. Tempat diperbadankan/dibentuk ....................................................
Place of incorporation/formation
5. Alamat pejabat berdaftar
Address of registered office
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
No. telefon ......................................................................
Telephone no. | No. faks .................................................................
Fax no. |
Alamat mel elektronik ........................................................
E-mail address
6. Alamat pejabat lain (jika ada)
Address of other offices (if any)
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
No. telefon ......................................................................
Telephone no. | No. faks .................................................................
Fax no. |
Alamat mel elektronik ........................................................
E-mail address
7. Butir-butir pengarah/pekongsi
Particular of directors/partners
Nama dan alamat kediaman
Name and residential address | Kerakyatan
Nationality | % saham yang dipegang dalam syarikat/ % pengkongsian
% of share held in company/ % of partnership |
| | |
8. Pengakuan
Declaration
(a) Adakah penerima, atau penerima dan pengurus, pernah dilantik berkenaan dengan apa-apa harta pemohon?
Has a receiver, or a receiver and manager, been appointed in respect of any of the applicant`s asset? | Ya/Tidak
Yes/No |
(b) Adakah pemohon telah mencapai kata sepakat atau membuat perkiraan dengan pemiutang?
Has the applicant entered into a compromise or arranngement with creditors? | Ya/Tidak
Yes/No
|
(c) Adakah petisyen telah dikemukakan ke mahkamah untuk menggulungkan pemohon
Has a petition been presented in a court for the winding up of the applicant? | Ya/Tidak
Yes/No |
_____________________________________________
B. KOS PENGENDALIAN
OPERATIONAL COSTS
_____________________________________________
| Jumlah
Total |
1. Harta tetap (sila nyatakan)
Fixed assets (please specify) | RM |
| (a) ................................................................................................................... | ......................................................... |
| (b) .................................................................................................................... | .......................................................... |
| (c) ................................................................................................................... | .......................................................... |
Jumlah harta tetap
Total fixed assets | ......................................................... |
2. Perbelanjaan sebelum pengendalian
Pre-operational costs | .................................................................. |
3. Modal kerja
Working capital | .................................................................. |
4. Perlindungan insurans
Insurance coverage | ................................................................. |
Jumlah
Total | .................................................................. |
Nota : Jika tanah, bangunan atau kelengkapan disewa/dipajak, nyatakan kos sewaan/pajakan tahunan.
Note: If the land, building or equipment is rented/leased, specify the annual cost of rental/ lease.
___________________________________________________
C. SUMBER KEWANGAN
FINANCING
___________________________________________________
| RM | % |
1. Modal dibenarkan
Authorised capital | .................................... | .................................... |
2. Modal dibayar
Paid-up capital | | |
(a) Perkongsian
Partnership
| ................................... | ................................... |
(b) Syarikat yang diperbadankan di Malaysia*
Companies incorporated in Malaysia*
| | |
.....................................................................................
.....................................................................................
| ....................................
.................................... | ....................................
.................................... |
(c) Syarikat/perkongsian asing (Nyatakan nama dan negara)
Foreign company/partnership (Specify name and country)
| | |
.....................................................................................
.....................................................................................
| ....................................
.................................... | ....................................
.................................... |
Jumlah (a), (b) dan (c)
Total of (a), (b) dan (c)
| ---------------------------- | 100% |
*Bagi 2(b) nyatakan struktur ekuiti seperti berikut:
For 2)(b) provide equity structure as follows: | | |
Nama syarikat .........................................................
Name of company | Nama syarikat .........................................................
Name of company |
Bumiputera .................................%
Bumiputera | Bumiputera .................................%
Bumiputera |
Bukan Bumiputera .........................%
Non-Bumiputera | Bukan Bumiputera .........................%
Non-Bumiputera |
Rakyat asing ....................................%
Foreign national | Rakyat asing ....................................%
Foreign national |
3. Pinjaman
Loan | RM |
| .............................................. |
| .............................................. |
Jumlah
Total | ---------------------------------- |
4. Sumber lain (sila nyatakan)
Other sources (please specify) | RM |
.................................................................
.................................................................
................................................................. | .............................................
.............................................
............................................. |
Jumlah
Total | ---------------------------------- |
Jumlah 2, 3 dan 4
Total of 2, 3 and 4 | --------------------------------- |
5. Berikan nama mana-mana syarikat lain yang menjalankan/ mengendalikan kegiatan yang seumpamanya yang dalamnya mana-mana pemegang saham syarikat pemohon/pekongsi pengkongsian pemohon atau syarikat pemohon / perkongsian pemohon mempunyai penyertaan ekuiti.
State the names of any other company carrying on/operating a similar activity in which any shareholders of the applicant company/partners of the applicant partnership or the applicant company/applicant partnership has equity participation.
....................................................................................................................
....................................................................................................................
....................................................................................................................
....................................................................................................................
Nota: Sertakan sesalinan akaun terakhir yang diaudit.
Note: Attach a copy of the latest audited accounts.
BAGI PIHAK BERKUASA PEMERAKUAN SAHAJA.
FOR CERTIFICATION AUTHORITY ONLY.
6. Jaminan sesuai yang difailkan dengan Pengawal.
(Untuk peringkat pengendalian sahaja).
Suitable guarantee to be filed with the Controller.
(For operation stage only).
RM .....................................................................................................
Nota: Sertakan jaminan sesuai yang berkenaan.
Note: Attach relevant suitable guarantee.
_________________________________________________
D. GUNA TENAGA
MANPOWER
_________________________________________________
1. Kakitangan dan pekerja
Staff and workers
2. Butir-butir kakitangan yang berijazah sains dan teknikal atau berkelayakan yang setaraf dengannya*
Particular of staff holding science and technical degrees or an equivalent qualification*
Jawatan
Designation | Fungsi tugas
Job function | Kelayakan
Qualification | Bilangan
Number |
| | | |
| | Jumlah
Total | |
*Tidak termasuk diploma dan sijil kelulusan lain yang lebih rendah.
Excluding diplomas and other lower level certificates.
Nota: Sertakan salinan sijil yang berkenaan.
Note: Attach copies of relevent certificates.
3. Pengakuan
Declaration
(a) Adakah pemohon atau mana-mana orang yang diambil kerja oleh atau selainnya berkaitan dengan pemohon
Has the applicant or any person employed by or otherwise associated with the applicant |
(i) pernah disabitkan dalam 15 tahun yang lepas atas kesalahan yang melibatkan fraud, kenyataan palsu atau perdayaan?
been convicted within the past 15 years of an offence involving fraud, false statement and deception? | Ya/Tidak
Yes/No |
(ii) pernah didapati berliabiliti kerana pelanggaran kewajipan fidusiari atau kecuaian ikthisas atau salah nyata dalam apa-apa prosiding sivil?
been found liable of a breach of fiduciary duty or professional negligence or misrepresentation in any civil proceedings? | Ya/Tidak
Yes/No |
(iii) pernah melanggar mana-mana undang-undang bertulis yang bertujuan melindungi orang awam daripada kerugian kewangan akibat kecurangan, ketidakcekapan atau amalan salah oleh orang yang membekalkan perkhidmatan kewangan atau pengurusan syarikat atau daripada kerugian kewangan akibat tindakan bankrap yang dilepaskan atau tak dilepaskan?
contravened any written law designed to protect the public from financial loss due to the dishonesty, incompetence or malpractice of persons providing financial services or the management of companies or against financial loss due to the conduct of a discharged or undischarged bankrupt? | Ya/Tidak
Yes/No |
(iv) pernah dikenakan apa-apa prosiding tatatertib atau tindakan lain oleh mana-mana badan ikhtisas atau kawal selia?
been subjected to any disciplinary proceeding or other action by any professional or regulatory body? | Ya/Tidak
Yes/No |
(b) Adakah apa-apa prosiding undang-undang terhadap pemohon atau mana-mana orang yang diambil kerja oleh atau selainnya berkaitan dengan pemohon yang masih belum selesai yang boleh menghasilkan dapatan dalam subperenggan (a)(i),(ii) atau (iii)?
Is any legal proceeding pending against the applicant or any person employed by or otherwise associated with the applicant that could result in a finding in subparagraph (a)(i),(ii) or (iii)? | Ya/Tidak
Yes/No |
Nota: Adalah disyorkan supaya siasatan yang perlu dijalankan sebelum pengakuan ini dibuat.
Note: It is recommended that the necessary inquiries be carried out before this declaration is made.
4. Berikan carta organisasi yang dicadangkan dan tandakan kedudukan jawatan-jawatan yang dinyatakan dalam D2
Provide the proposed organisation chart and indicate the position of the posts specified in D2.
________________________________________________
E. TATACARA PENGENDALIAN
OPERATING PROCEDURE
________________________________________________
1. Berikan carta aliran proses pemerakuan/pengendalian dan terangkan proses-proses utama.
Provided the certification/operating process flow chart and explain the main processes.
Nota: Dalam hal repositori, masukkan-
(a) tatacara bagi memproses perakuan yang baru disiarkan serta notis penggantungan dan pembatalan; dan
(b) proses untuk mengambil kira penggunaan respositori dan jalan masuk kepada maklumat yang disiarkan di dalamnya.
Dalam hal perkhidmatan penanda tarikh/masa, masukkan-
(a) tatacara bagi memproses dokumen yang diterima; dan
(b) proses untuk mengambil kira penggunaan perkhidmatan.
Note: In the case of a repository, include-
(a) procedures for processing newly published certificates and notices of suspension and revocation; and
(b) processes to account for usage of the respository and access to the information published in it.
In the case of a date/time stamp service, included-
(a) procedures for processing document received; and
(b) processes to account for usage of the service.
2. Berikan salinan pernyataan amalan pemerakuan/pengendalian yang dicadangkan.
Provide a copy of the proposed certification/operating practice statement.
3. Nyatakan langkah-langkah untuk memeriksa identiti pelanggan.
Specify the measures to be taken to check the identity of subcribers.
4. Nyatakan repositori yang akan digunakan.
Specify the repositories to be used.
Dikendalikan sendiri ..........................................
Self- operated | Lain-lain (sila nyatakan) ..........................................
Others (please specify)
..........................................
.......................................... |
5. Nyatakan perkhidmatan penanda tarikh/masa yang akan digunakan.
Specify the date/time stamp services to be used.
Dikendalikan sendiri ..........................................
Self- operated | Lain-lain (sila nyatakan) ..........................................
Others (please specify)
..........................................
.......................................... |
6. Nyatakan butir-butir sistem boleh dipercayai yang akan digunakan, khususnya piawaian dan komponen teknikal.
Specify the particulars of the trustworthy system to be used, in particular the standards and technical components.
7. Nyatakan butir-butir skim tandatangan digital diluluskan yang akan digunakan.
Specify the particulars of the approved digital signature scheme to be used.
8. Berikan butir-butir mengenai pengkalan data yang akan disenggarakan, termasuk bentuk dan struktur.
Provide details of the data base to be maintained, including form and structure.
9. Nyatakan kriteria untuk menentukan-
(a) dalam hal repositori, siapa yang boleh menyiarkan maklumat dalam repositori dan cara kriteria ini akan dikuatkuasakan di sisi undang-undang; dan
(b) dalam hal perkhidmatan penanda/tarikh/masa, keutamaan penandaan masa dokumen yang diterima.
Specify the criteria for determining -
(a) in the case of a repository, who may publish information in the respository and the legal means by which such criteria are given effect; and
(b) in the case of a date/time stamp service, the priority of time-stamping of documents received.
10. Berikan laporan daripada juruaudit yang layak.
(Untuk peringkat pengendalian sahaja).
Provide a report from a qualified auditor.
(For operation stage only).
__________________________________________________
F. SUMBER PENGETAHUAN TEKNIKAL
SOURCES OF TECHNICAL KNOW-HOW
__________________________________________________
| Nama dan alamat pembekal | Tempoh dan jenis pengalaman | Nama syarikat lain di dunia yang mempunyai pengetahuan seumpamanya. | Hubungan dengan pemohon (cth.: syarikat induk/ bersekutu) |
| Name and address of supplier | Year and type of experience | Name of other company in the world with similar know-how | Relationship with applicant (e.g.:parent /associate company) |
| .................................................... | .................................................... | .................................................... | .................................................... |
| .................................................... | .................................................... | .................................................... | .................................................... |
__________________________________________________
G. SENARAI PERKHIDMATAN
LIST OF SERVICES
__________________________________________________
Perkhidmatan
Service | Fi dan caj
Fees and charges
(RM) |
| |
___________________________________________________
H. PENGAKUAN
DECLARATION
___________________________________________________
Saya ............................................., mengaku bahawa sebaik-baiknya yang saya tahu dan percaya butir-butir yang diberikan dalam permohonan ini adalah benar.
I, ....................................................., declare that to the best of my knowledge and belief the pariculars furnished in this application are true.
Saya juga mengaku bahawa saya faham dan membenarkan penzahiran apa-apa maklumat yang terkandung dalam permohonan ini sebagaimana yang didapati perlu oleh Pengawal Pihak Berkuasa Pemerakuan.
I also declare that I understand and consent to the disclosure of any information contained in this application as the Controller of Certification Authorities considers necessary.
Tarikh ....................................................
Date | ..........................................
(Tandatangan pemohon)/
(Signature of applicant) |
............................................
(Jawatan)/(Designation)
BORANG 2 / FORM 2
[Peraturan 10 / Regulation 10]
AKTA TANDATANGAN DIGITAL 1997 /
DIGITAL SIGNATURE ACT 1997
PERATURAN-PERATURAN TANDATANGAN DIGITAL 1998/
DIGITAL SIGNATURE REGULATIONS 1998
LESEN PIHAK BERKUASA PEMERAKUAN
CERTIFICATION AUTHORITY LICENCE
Peringkat ........................................
ASAL
ORIGINAL
No. Siri:
Serial no.: | No. Lesen:
Licence No.: |
MENURUT SEKSYEN 8 AKTA TANDATANGAN DIGITAL 1997
PURSUANT TO SECTION 8 OF THE DIGITAL SIGNATURE ACT 1997
Saya memberi lesen kepada ..........................................................................
I licence ............................................................................................................................... (Nama pemohon / Applicant's name)
(a) untuk menubuhkan sebagai*
to establish as a*
(b) untuk menjalankan atau mengendalikan sebagai*
to carry on or operate as a*
PIHAK BERKUASA PEMERAKUAN BERLESEN mulai dari ............................................................
LICENSED CERTIFICATION AUTHORITY as from .......................................... (Tarikh/Date)
di pejabat atau pejabat-pejabat yang beralamat seperti berikut :
at the following office or offices:
..................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
..................................................................................................................
tertakluk kepada syarat yang dilampirkan bersama lesen ini:
subject to the conditions attached to this licence:
__________________________________________________
*Potong mana-mana yang tidak berkenaan.
Delete whichever is not applicable.
ASAL
ORIGINAL
No. Siri:
Serial No.:
1. Nama pemilik lesen .....................................................................................
Name of owner of licence
2. Alamat perniagaan .......................................................................................
Business address
...............................................................................................................................
...............................................................................................................................
...............................................................................................................................
..............................................................................................................................
3. Tarikh dan masa dikeluarkan ....................................................................
Date and time of issue
4. Tarikh dan masa habis tempoh ................................................................
Date of time of expiry
5. Rujukan fail ....................................................................................................
File reference
6. No. Resit .....................................................................
Receipt No.
7. Amaun dibayar ..........................................................
Amount paid
.............................................................
Pengawal Pihak Berkuasa Pemerakuan/
Controller of Certification Authorities
BORANG 3 / FORM 3
[Peraturan 13 / Regulation 13]
AKTA TANDATANGAN DIGITAL 1997 /
DIGITAL SIGNATURE ACT 1997
PERATURAN-PERATURAN TANDATANGAN DIGITAL 1998/
DIGITAL SIGNATURE REGULATIONS 1998
PERMOHONAN BAGI LESEN PENDUA
APPLICATION FOR DUPLICATE LICENCE
__________________________________________________
A. BUTIR-BUTIR PEMOHON
PARTICULARS OF APPLICANT
__________________________________________________
1. Nama pemohon dan alamat surat-menyurat
Name of applicant and correspondence address
....................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
No. telefon ..............................
Telephone no. | No. faks ................................
Fax no. | Orang untuk dihubungi ...............................................................
Contact person |
Alamat mel elektronik .......................................................................................................
E-mail address
Jawatan ......................................................................
Designation
2. Nama pembezaan pemohon
Distinguished name of applicant
....................................................................................................................
....................................................................................................................
3. Tarikh diperbadankan/dibentuk ....................................................................................
Date of incorporation/formation
4. Tempat diperbadankan/dibentuk ..................................................................................
Place of incorporation/formation
5. Alamat pejabat berdaftar
Address of registered office
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
No. telefon ..............................
Telephone no. | No. faks ................................
Fax no. |
Alamat mel elektronik ........................................................
E-mail address
6. Alamat pejabat lain (jika ada)
Address of other offices (if any)
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
...................................................................................................................
No. telefon ..............................
Telephone no. | No. faks ................................
Fax no. |
Alamat mel elektronik ........................................................
E-mail address
__________________________________________________
B. BUTIR-BUTIR LESEN
PARTICULAR OF LICENCE
__________________________________________________
1. No. Lesen ...........................................
Licence No. | No. Siri .................................................
Serial No. |
2. Tarikh dan masa dikeluarkan .............................................................
Date and time of issue
3. Tarikh dan masa habis tempoh .........................................................
Date of time of expiry
4. Rujukan fail ............................................................................................
File reference
___________________________________________________
C. MAKLUMAT LAIN YANG BERKENAAN
OTHER RELEVANT INFORMATION
___________________________________________________
Nyatakan sebab Lesen Pendua diperlukan
State the reason for requiring a Duplicate Licence
...................................................................................................................
....................................................................................................................
....................................................................................................................
...................................................................................................................
Nota: sertakan apa-apa dokumen yang berkenaan.
Note: Attach any relevant documents.
__________________________________________________
D. PENGAKUAN
DECLARATION
__________________________________________________
Saya ............................................., mengaku bahawa sebaik-baiknya yang saya tahu dan percaya butir-butir yang diberikan dalam permohonan ini adalah benar.
I, ....................................................., declare that to the best of my knowledge and belief the pariculars furnished in this application are true.
Saya juga mengaku bahawa saya faham dan membenarkan penzahiran apa-apa maklumat yang terkandung dalam permohonan ini sebagaimana yang didapati perlu oleh Pengawal Pihak Berkuasa Pemerakuan.
I also declare that I understand and consent to the disclosure of any information contained in this application as the Controller of Certification Authorities considers necessary.
Tarikh ....................................................
Date | ..........................................
(Tandatangan pemohon)/
(Signature of applicant) |
............................................
(Jawatan)/(Designation)
BORANG 4 / FORM 4
[Peraturan 26 / Regulation 26]
AKTA TANDATANGAN DIGITAL 1997 /
DIGITAL SIGNATURE ACT 1997
PERATURAN-PERATURAN TANDATANGAN DIGITAL 1998/
DIGITAL SIGNATURE REGULATIONS 1998
NOTIS TUNTUTAN
NOTICE OF CLAIM
_________________________________________________
A. BUTIR-BUTIR PENUNTUT
PARTICULARS OF CLAIMANT
_________________________________________________
1. Nama pemohon dan alamat surat-menyurat
Name of applicant and correspondence address
..................................................................................................................
..................................................................................................................
.................................................................................................................
.................................................................................................................
No. telefon ..............................
Telephone no. | No. faks ................................
Fax no. | Orang untuk dihubungi ...............................................................
Contact person |
Alamat mel elektronik ........................................................................................................
E-mail address
Jawatan ......................................................................
Designation
2. Nama pembezaan penuntut
Distinguished name of claimant
.............................................................................................................
.............................................................................................................
__________________________________________________
B. BUTIR-BUTIR PIHAK BERKUASA PEMERAKUAN BERLESEN
PARTICULARS OF LICENSED CERTIFICATION AUTHORITY
__________________________________________________
1. Nama pihak berkuasa pemerakuan berlesen
Name of licensed certification authority
..............................................................................................................
..............................................................................................................
..............................................................................................................
2. Alamat perniagaan
Business address
..............................................................................................................
..............................................................................................................
..............................................................................................................
No. telefon ..............................
Telephone no. | No. faks ................................
Fax no. | Orang untuk dihubungi ...............................................................
Contact person |
Alamat mel elektronik .................................................................................
E-mail address
Jawatan ......................................................................
Designation
3. Nama perbezaan .......................................................................................
Distinguished name
4. No. Lesen ...........................................
Licence No. | No. Siri .................................................
Serial No. |
5. Tarikh dan masa dikeluarkan .....................................................................
Date and time of issue
6. Tarikh dan masa habis tempoh ................................................................
Date of time of expiry
____________________________________________________
C. BUTIR-BUTIR JAMINAN SESUAI
PARTICULARS OF SUITABLE GUARANTEE
____________________________________________________
1. Nama pengeluar jaminan sesuai
Name of issue of the suitable guarantee
........................................................................................................................
.......................................................................................................................
.......................................................................................................................
2. Alamat pejabat berdaftar
Address of registered office
........................................................................................................................
.......................................................................................................................
.......................................................................................................................
No. telefon ..............................
Telephone no. | No. faks ................................
Fax no. | Orang untuk dihubungi ...............................................................
Contact person |
Alamat mel elektronik .................................................................................
E-mail address
Jawatan ......................................................................
Designation
3. Alamat pejabat lain (jika ada)
Address of other offices (if any)
........................................................................................................................
.......................................................................................................................
.......................................................................................................................
No. telefon ..............................
Telephone no. | No. faks ................................
Fax no. |
Alamat mel elektronik ........................................................
E-mail address
4. Amaun jaminan sesuai .....................................................
Amount of suitable guarantee
5. Tempoh sah ..........................................................
Period of validity
___________________________________________________
D. BUTIR-BUTIR TUNTUTAN
PARTICULARS OF CLAIM
___________________________________________________
1. Alasan bagi mendapatkan hak terbatas untuk mendapat bayaran.
Grounds for recovery of qualified right to payment.
Nota: Sertakan salinan terperaku penghakiman mahkamah yang berkenaan dan apa-apa dokumen lain yang berkenaan.
Note: Attach a certified copy of the relevent court judgment and any other relevant documents.
2. Amaun dituntut .........................................................
Amount claimed
__________________________________________________
E. PENGAKUAN
DECLARATION
__________________________________________________
Saya ............................................., mengaku bahawa sebaik-baiknya yang saya tahu dan percaya butir-butir yang diberikan dalam permohonan ini adalah benar.
I, ....................................................., declare that to the best of my knowledge and belief the pariculars furnished in this application are true.
Saya juga mengaku bahawa saya faham dan membenarkan penzahiran apa-apa maklumat yang terkandung dalam permohonan ini sebagaimana yang didapati perlu oleh Pengawal Pihak Berkuasa Pemerakuan.
I also declare that I understand and consent to the disclosure of any information contained in this application as the Controller of Certification Authorities considers necessary.
Tarikh ....................................................
Date | ..........................................
(Tandatangan pemohon)/
(Signature of applicant) |
............................................
(Jawatan)/(Designation)
BORANG 5 / FORM 5
[Peraturan 54 DAN 67 / Regulation 54 and 67]
AKTA TANDATANGAN DIGITAL 1997 /
DIGITAL SIGNATURE ACT 1997
PERATURAN-PERATURAN TANDATANGAN DIGITAL 1998/
DIGITAL SIGNATURE REGULATIONS 1998
PERAKUAN PENGIKTIRAFAN BAGI REPOSITORI/
PERKHIDMATAN PENANDA TARIKH/MASA*
CERTIFICATE OF RECOGNITION FOR REPOSITORY/
DATE/TIME STAMP SERVICE*
Peringkat .....................................
Stage
ASAL
ORIGINAL
No. Siri :
Serial No.: | No. Perakuan:
Certificate No.: |
MENURUT SEKSYEN 68/70* AKTA TANDATANGAN DIGITAL 1997
PURSUANT TO SECTION 68/70* OF THE DIGITAL SIGNATURE ACT 1997
Saya memperakui ........................................................................................ (Nama pemohon / Applicant's name)
I certify
sebagai suatu REPOSITORI DIIKTIRAF/PERKHIDMATAN PENANDA TARIKH/MASA DIIKTIRAF*
as a RECOGNISED REPOSITORY/RECOGNISED DATE/TIME STAMP SERVICE*
PERINGKAT ........................................................................... mulai dari ..............................................................
STAGE ........................................................................... as from ........................................................................... (Tarikh/Date)
di pejabat atau pejabat-pejabat yang beralamat seperti berikut:
at the following office or offices:
...........................................................................................................
...........................................................................................................
...........................................................................................................
tertakluk kepada syarat yang dilampirkan bersama perakuan ini:
subject to the conditions attached to this certificate:
________________________________________________
*Potong mana-mana yang tidak berkenaan.
Delete whichever is not applicable.
ASAL
ORIGINAL
No. Siri:
Serial No.:
No. Perakuan:
Certificate No.:
Name of owner of certificate
2. Alamat perniagaan .........................................................................................
Business address
...............................................................................................................................
..............................................................................................................................
..............................................................................................................................
3. Tarikh dan masa dikeluarkan ...................................................................
Date and time of issue
4. Tarikh dan masa habis tempoh ..............................................................
Date and time of expiry
5. Rujukan fail ....................................................................................
File reference
6. No. Resit ........................................................................................
Receipt No.
7. Amaun dibayar ..............................................................................
Amount paid
..........................................................................
Pengawal Pihak Berkuasa Pemerakuan/
Controller of Certification Authorities
