MDEC TALENT EXPERT NETWORK (TEN) MEMBERSHIP 2022/01

Section 1 : Personal Information
Name as per IC/Passport*
IC No./Passport No*
Please upload copy of your IC/Passport*

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Designation*
Email*
example@example.com
Company*
Contact Number (Mobile)*
Note: Please enclose together with the form certified true copy of SSM Search*

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Cancelof
Sample of SSM Search

Section 2 : Declaration of Directorship & Shareholding
*To insert details if the Director(s) or Shareholder(s) of the applicant’s Company has:-

1. family member(s) working or holds the directorship and shareholding position(s) in MDEC; or

2. business relationship with MDEC
Name of Company
Company Registration Number
Date of Incorporation
Telephone No.
Fax No.
Business Address as per SSM

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Contact Person
Designation of Contact Person
Contact Number of Contact Person
Email of Contact Person
example@example.com

b) Directorship Particular

	Name	NRIC/ Passport Number	Designation	Date of Appointment	Does the individual have a close business relationship with MDEC? If yes, please provide the details of the business relationship	Does the individual have close family relationship with MDEC Director/Employee? If yes, please provide the details of the MDEC's Director/Employee and relationship
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c) Shareholding Structure (max to 10 information)

	Name (Individual /Company)	NRIC/Passport/BRIC Number	Nationality	Amount of shareholding (RM)	Percentage of shareholding	Does the individual/ company have close business relationship with MDEC? If yes, please provide the details of the business relationship	Does the individual have close family relationship with MDEC Director/Employee? If yes, please provide the details of the MDEC’s Director/Employee and relationship.
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Section 3 : Field of Expertise and Experiences
Focus Area(s) of Expertise*

Data ScienceDigital Global Business Services (GBS)Digital MarketingCloudFintechArtificial Intelligence (AI)DroneGameCybersecuritySoftware DevelopmentAnimationIOT

Years of Experience in Related Field(s) above*

Section 8 : Declaration on the information provided and consent for disclosure of information
By submitting this application form, I hereby declare and
states as follows:
Should be Empty: