BORANG PERMOHONAN WAKIL PENGEDAR GAS PETRONAS

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1 Title: Application Form for Appointment of LPG Dealer Reference: LPGBD/BD/CDMU/F/01 Revision: Borang ini diberi PERCUMA BORANG PERMOHONAN WAKIL PENGEDAR GAS PETRONAS Perhatian : 1. Sila baca dengan teliti dan jawab semua soalan 2. Potong mana yang tidak berkenaan * 3. Tandakan X bagi kotak yang berkenaan 4. Sila catat Tidak Ada bagi yang tidak berkenaan Lekatkan Gambar Warna Terbaru 1. Nama Pemohon / Syarikat : 2. Alamat : Tel : 3. Taraf hak milik perniagaan : *Perseorangan / Perkongsian / Berhad / Koperasi / Syarikat Sdn.bhd 4. Sila senaraikan nama-nama pemilik saham utama (Jika perkongsian / Syarikat Sdn Berhad / Berhad / Koperasi ) NO NAMA & ALAMAT NO. KAD JUMLAH SAHAM PENGENALAN KUANTITI PERATUS UNTUK KEGUNAAN PDB SAHAJA TARIKH T/TANGAN i. Borang permohonan diterima ii. Ditemuduga iii. Keputusan: Ditolak / Dilantik iv. Catatan

2 5. Sila nyatakan kedudukan modal : (Jika Syarikat Sdn.Berhad / Koperasi / Berhad) (i) a) Modal berbayar (Paid up capital) : b) Modal yang dibenarkan : (Authorised Capital) (ii) Ekuiti a) Bumiputera : % b) Bukan Bumiputera : % c) Jumlah : % 6. Pihak yang menguruskan perniagaan : *Sendiri / Kongsi / Pengurus Bergaji 7. Nama *Kongsi / Pengurus Bergaji : 8. Pengetahuan dan pengalaman : Ada Tidak Ada dalam perniagaan GPC Tahun / Bulan 9. Adakan anda mempunyai sebarang lessen : perniagaan? Jika ada sebutkan nombornya 10. Pekerjaan dahulu : 11. Jenis Perniagaan Sekarang : 12. Kenderaan yang dimiliki : *Lori / Pick-Up Van / Lain-lain / Tidak Ada 13. Kawasan cadangan pengedaran Gas Petronas : 14. Adakah sekarang ini menjual gas memasak a) Ada Tidak Ada b) Jualan sebulan silinder (12kg / 14kg) Jualan sebulan silinder (50kg) c) Jenis: PETRONAS, ESSO, SHELL, MOBIL, BP, Lain-lain 15. Jika ada, adakah tuan / puan terikat dengan sebarang perjanjian dengan : Ada Tidak Ada syarikat pengeluar gas? 16. Jika ada Syarikat mana :

3 17. Pernahkan anda membuat permohonan menjadi Wakil Pengedar Gas Petronas Ada Tidak Ada sebelum ini? Jika ada, sebutkan tarikh dan kawasan Pengedaran : 18. Alamat tempat / kedai perniagaan yang : sedia ada 19. Jenis bangunan kedai yang sedia ada : Tingkat bawah Tingkat atas 20. Kedudukan kedai / stor : Ditepi jalan dan ada kemudahan lori keluar / masuk Jauh dari jalan utama 21. Alamat cadangan tempat stor silinder : 22. Jenis stor yang dicadangkan : Bilik stor yang berkembar Stor yang berasingan Diperbuat daripada kayu / papan sahaja Diperbuat daripada batu / bata sahaja Diperbuat daripada batu dan bata 23. Jumlah ruang di kedai / stor yang boleh mempamirkan barang-barang kegunaan : kaki persegi Gas Petronas (Jika ada) 24. a) Modal pusingan yang hendak dilaburkan : RM di dalam perniagaan gas (Sila sertakan salinan Penyata Kewangan untuk 6 bulan terakhir atau bukti-bukti kewangan yang lain) b) Berapa jumlah jaminan bank yang dapat : RM disediakan?

4 25. Jika anda ditawarkan menjadi Wakil Pengedar, bilakah perniagaan tersebut dapat dimulakan? : Saya / Kami akui bahawa keterangan-keterangan yang diberikan di dalam borang ini adalah benar. Saya / Kami memberi kuasa kepada Petronas Dagangan Berhad untuk menyisat semua kenyataan-kenyataan yang terkandung dalam proses pemilihan ini. Saya / Kami memahami pemberian butir-butir yang palsu atau yang sengaja ditinggalkan adalah cukup untuk menjadi alasan bagi pihak Petronas Dagangan Berhad membatalkan pertimbangan untuk melantik Wakil Pengedar atau sekiranya saya / kami telah dilantik boleh dibatalkan perlantikan tersebut. Saya / Kami akui dan menerima keputusan yang dibuat di atas permohonan saya/kami oleh pihak Petronas Dagangan Berhad adalah muktamad. Tandatangan : Tarikh : Nama : Cop Syarikat: SYARAT-SYARAT UTAMA BAGI PERLANTIKAN WAKIL PENGEDAR 1. Kawasan pemasaran yang dicadangkan masih belum mempunyai Wakil Pengedar PETRONAS yang sah dilantik. 2. Mempunyai kedai di mana perniagaan sedang dijalankan serta mempunyai ruang simpanan yang sesuai. (Kelulusan Jabatan Bomba dan Majlis Tempatan bagi simpanan gas). 3. Mempunyai modal perniagaan sekurang-kurangnya RM50, atau sanggup menyediakan Jaminan Bank bagi cagaran silinder, harga gas dan alat-alatan berkenaan. 4. Sanggup menyediakan kenderaaan seperti lori, motosikal beroda tiga (tricycle) atau van untuk membuat penghantaran ke rumah pelanggan-pelanggan. 5. Tidak menjalankan perniagaan apa-apa bahan petroleum dengan nama syarikat minyak yang lain.

5 SILA PASTIKAN DOKUMEN-DOKUMEN BERIKUT DISERTAKAN BERSAMA BORANG PERMOHONAN INI 1. Bagi Syarikat Pemilik Tunggal / Perkongsian a. Borang Pendaftaran Perniagaan iaitu A atau B dan D. b. Salinan Kad Pengenalan. 2. Bagi Syarikat Sendirian Bhd / Koperasi / Berhad a. Memorandum and Articles of Association b. Sijil Perbadanan Syarikat (Borang 9 Akta Syarikat 1965) c. Borang 24 Return of Allotment of Shares d. Borang 49 Return of Giving Particulars of Register of Directors, Manager and Secretaries and Change of Particulars e. Form of Annual return of company having a Share Capital (Pursuant to Section 165) di bawah The Companies Act f. Sijil Pendaftaran Koperasi g. Buku Undang-undang Kecil Koperasi

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