MDEC TALENT EXPERT NETWORK (TEN) MEMBERSHIP 2022/01

Name as per IC/Passport
IC No./Passport No
Please upload copy of your IC/Passport

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Cancelof
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

*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

Rows	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)

Rows	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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Years of Experience in Related Field(s) above