ICA 10 www.mida.gov.my (09.03.2012) Malaysian Investment Development Authority APPLICATION FOR CONFIRMATION LETTER FOR A COMPANY EXEMPTED FROM MANUFACTURING LICENCE UNDER THE INDUSTRIAL CO-ORDINATION ACT 1975 (AMENDMENT) 1. Name of company : ___________________________________________________ Date of Incorporation: ______________Company Registration No: _______________ Income Tax Ref. No:________________ Income Tax Branch Office: _____________ 2. Registered Address : __________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 3. Telephone no. ________________________________________________________ Fax: ___________________________ E-Mail : __________________________________ 4. Managing Director / General Manager : ________________________________ 5. Factory Location: _____________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 6. No. of Full Time Employment: ___________________________________________ 7. Total Project Cost: 8. Paid-up Capital / Shareholders’ Fund: _____________________________________ 9. Equity 10. __________________________________________________ Bumiputera : ____________________ % Non-Bumiputera : ____________________ % Foreign : ____________________ % Product: ____________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ICA 10 11. Incentive (if any): _____________________________________________________ ___________________________________________________________________ 12. Estimated Production Capacity for the first 3 Years in operation (Quantity / value): ___________ 13. Market: Domestic : ____________ % Export : ____________ % _________________________________________________________________________ 14. DECLARATION __________________________________________________________________ I, (i) , the Managing Director of hereby declare that to the best of my knowledge, the particulars furnished in this application are true. (ii)* have engaged/is planning to engage the services of the following consultant for my application : Company Name : Address : Contact Person : Designation : Telephone no. : Fax no. : E-mail : I take full responsibility for all information submitted by the consultant(s). Date (Signature) *Please complete this section if the company has engaged/is planning to engage the services of consultant(s) to act on behalf of the company. Please provide information on a separate sheet of paper if space is insufficient