SUPERB Application Form to Participate in the Business
ChallengePlease complete this form and email it back to
[email protected] your email subject as: SUPERB
Application : You can also attach any relevant additional
information.The closing date for the 1st round of applications is
on 21 February 2014, 5.30pm.
Idea Title :
Personal DetailsTeam Leader
Name:
Gender:
Date of Birth:
MyKad Number:
Marital Status:
Number of Children (if any):
Language(s) Spoken:
Education/Qualification:
Home Address:
Mobile Number(s):
Email :
I am a(n)Student
Employee
Professional
Unemployed
Entrepreneur
Family business background:
Previous employer(s):
Personal DetailsTeam Member 1
Name:
Gender:
Date of Birth:
MyKad Number:
Education/Qualification:
Home Address:
Mobile Number(s):
Email :
I am a(n)Student
Employee
Professional
Unemployed
Entrepreneur
Family business background:
Previous employer(s):
Team Member 2
Name:
Gender:
Date of Birth:
MyKad Number:
Education/Qualification:
Home Address:
Mobile Number(s):
Email :
I am a(n)Student
Employee
Professional
Unemployed
Entrepreneur
Family business background:
Previous employer(s):
Company (if already incorporated)
Company Name:
Company Number:
Company Address:
Company Shareholders:
Company Directors:
Paid-Up Capital (RM):
Date of Incorporation:
Years in Operation:
Nature of Business:
Revenue for 2013:
Profit after tax for 2013:
Please answer the questions below regarding your
idea/product/solution:
1. Tell us your business idea in less than 200 words
2. Why do you think it will work? What makes your business
unique?
3. Which sector does your business fall into?Communications,
Content & Infrastructure
Electronics & Electrical
Wholesale & Retail
Palm Oil & Rubber
Oil, Gas & Energy
Financial Services
Business Services
Healthcare
Agriculture
Education
Tourism
Other:
4. Has this idea been pitched or presented to other Government
agencies? If yes, which agencies?
5. How much did you invest your own money in this?
6. Tell us your team's experience and capability that makes you
capable of delivering this project. Please include relevant past
projects.
7. Who is your target market?
8. What would be your business model?
9. How much funds do you need and why do you need it?
Utilisation of fundingAmount (RM)
TOTAL
Declaration
Have you received any financial assistance from the Government
before? ( Yes / No )
If yes, which Government agency, how much, for what type of
project and state utilisation of funds
Please state which information provided in this application that
you do not agree to be used for the purposes of consolidation,
analysis, preparing statistics, marketing, advertising and
promotion via television and/or other mass or social media
I, , , hereby declare:
1. Acknowledgement a) I acknowledge that the submission of this
application does not create an obligation or guarantee on the part
of TERAJU to approve the application herein.
b) I hereby agree for TERAJU to process my personal data
provided herein for the purpose of this application.
c) I hereby acknowledge that while TERAJU will use reasonable
effort to safeguard the confidentiality of the information
submitted in this application, TERAJU shall be entitled to:
i. disclose the information submitted herein to such persons
involved in the evaluation process of this application including
without limitation TERAJUs employees, consultants, agents, advisors
and/or such other persons as may be appointed by TERAJU; and
ii. use any information submitted herein for the purposes of
consolidation, analysis, preparing statistics, marketing,
advertising and promotion via television and/or other mass or
social media, and if I do not agree that any part of the
information provided herein can be used for such purpose, I should
expressly identify such data and highlight the same to TERAJU in
advance in this application form.
d)I further acknowledge that TERAJU considers all submitted
applications as confidential and treats all team matters
accordingly. However, TERAJU cannot guarantee complete
confidentiality for proprietary matters. TERAJU is not responsible
for any proprietary information and/or intellectual property
included in a submitted application. Ultimately, I am solely
responsible to protect sensitive materials.
2.True and Accurate
I hereby declare that all information furnished, or to be
furnished, in connection with the Project and this application does
not contain any untrue statements and were honestly provided and
made upon due and careful inquiry and I have not omitted to state
any fact(s), the omission of which makes such statements
misleading.
3. Personal Data Protection Statement
I agree that, with regard to the personal data relating to the
other individual(s), which are provided to TERAJU in this
application form, I have obtained the following from such
individual(s):
1. his/her consent for TERAJU to process his/her personal data
provided in this application form, and any other additional
personal data which may be further provided to TERAJU in connection
with this application form;
1. his/her confirmation that his/her personal data provided are
complete and accurate;
1. his/her acknowledgment that he/she is entitled to obtain
access to and to request correction of the personal data provided
to TERAJU and that he/she can request TERAJU to cease processing
his/her personal data. For this purpose, he/she should contact
TERAJU, either by sending an email to
[email protected] or by sending a letter to TERAJU
at Level 5, Surian Tower No. 1, Jalan PJU 7/3 Mutiara Damansara,
47810 Petaling Jaya, Selangor Darul Ehsan; and
1. his/her consent that TERAJU may disclose his/her personal
data to:
0. any TERAJU vendor(s), contractor(s) and/or outsourcing
company(ies) engaged by TERAJU, for purposes in connection with
this application form; and/or
0. Government authorities, agencies and and/or any other
regulatory body, to the extent that the Government or other
authorities, agencies and/or any other regulatory body need to
know, or as permitted by applicable laws and regulations.
I further agree that in any event TERAJU receives any request by
any data subject for withdrawal of consent to process any personal
data provided herein, TERAJU has the right to treat this
application as null and void.
BY SUBMITTING THIS APPLICATION FORM TO TERAJU, I HEREBY CONFIRM
MY DECLARATION, ACKNOWLEDGEMENT AND AGREEMENT ON ALL THE
INFORMATION GIVEN AND TERMS STATED ABOVE
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