Communication and Multimedia Certification Section (CMCS) CMC/FOR/02-2

Product Certification& Inspection Department

SIRIM QAS International Sdn. Bhd.
Block 25, SIRIM Complex
No. 1, Persiaran Dato’ Menteri
P.O. Box 7035, 40911 Shah Alam
Selangor Darul Ehsan, Malaysia
Tel: 603-5544 6949, 6931 Fax: 603-5544 6912
_____________________________________________________________________________________
APPLICATION FORM FOR E-PERMIT (FOR NON-REGISTERED E-PERMIT USER)
A. IMPORT PERMIT DETAILS
Consignor Details Consignee Details
ROC/ROB *ROB/ROC 1
*Company Name *Company Name

*Company Address *Company Address

Agent Details Applicant Details

Agent Name *Applicant Name

Agent Code *Applicant Designation

Agent Address *Applicant IC/Passport
No.
*Applicant Tel. No
Applicant Fax. No
Applicant Email
Maritime
* Mode of Transport
(Please √ tick one ONLY) Rail
Road
Air
Post
*Purpose *Port /Place of Import
*Country of Origin *Location
*Place of Origin *Consigned From

*Permit Category Import for Repair (Complete set for re-export) Special Approval (Private)
(Please √ tick one ONLY)
Import for Repair (Parts for re-export) Special Approval (Trial)
Import for Re-export (Complete set) Special Approval (Research & Development)
Import for Re-export (Parts) Special Approval (Exhibition)
IT/Networking Product Special Approval (Demo)
Tax Exemption Special Approval (Training)
Antenna (except for satellite antenna) Special Approval (Market Survey)
Other telecommunication accessories
Note: 1. 1 : if the application is for individual, fill in IC No or Passport to replace ROC/ROB number.
2.* : Mandatory input for electronic permit application.
3. Non-Registered E-Permit User: Applicant (Individual / Company only) who did not registered with SIRIM QAS
International and Dagang Net Technologies Sdn. Bhd. to use the E-Permit System. SIRIM QAS International
shall apply in the System on behalf of applicant.
SIRIM QAS International Sdn. Bhd. Communication and Multimedia Certification Section Page 1 of 2
Issue: 1 Rev. : 0
 Communication and Multimedia Certification Section (CMCS) CMC/FOR/02-2
Product Certification& Inspection Department
SIRIM QAS International Sdn. Bhd.
Block 25, SIRIM Complex
No. 1, Persiaran Dato’ Menteri
P.O. Box 7035, 40911 Shah Alam
Selangor Darul Ehsan, Malaysia
Tel: 603-5544 6949, 6931 Fax: 603-5544 6912
_____________________________________________________________________________________

B. ITEM DETAILS
*Tariff Code
*Product Description

*Model No.

*Brand

*Tariff Quantity

*Unit Cost C.I.F

(RM)
Total Cost
(RM)
Special Condition
Part
(Please √ tick one
ONLY) Complete Set
C. DECLARATION AND UNDERTAKING.
In connection with this application, I/we:
(a) undertake to provide true and accurate information as required by SIRIM QAS International Sdn. Bhd. for the
purpose of application for e-permit;
(b) undertake to pay SIRIM QAS International Sdn. Bhd. all costs for processing this application;
(c) undertake to inform SIRIM QAS International Sdn. Bhd. if there is a change in the information from the earlier
submission;
(d) agree that SIRIM QAS International Sdn. Bhd. may release information obtained in the course of processing the
application to the public or government authorities so far as it is necessary in the opinion of SIRIM QAS
International Sdn. Bhd.;
(e) agree to allow SIRIM QAS International Sdn. Bhd. to key in the application details into the e-permit website for
the purpose of the application for e-permit;
(f) agree that SIRIM QAS International Sdn. Bhd. shall not be held responsible in the event the e-permit application
is rejected after the application details have been keyed in by SIRIM QAS International Sdn. Bhd. and agree to
pay surcharge, rejection , cancellation and any associated fee related to this application;
(g) hereby declare that all information submitted herewith are true and have read and fully understood and agree to
sign and abide by the terms & condition as stated in the SIRIM QAS International Sdn. Bhd. e-Permit
Subscriber Agreement.
Signature Company Stamp

Full Name

Designation

Date
Please return form duly completed to: For SIRIM QAS International Sdn. Bhd. use:
Communication and Multimedia Certification Section (CMCS) Received by
SIRIM QAS International Sdn. Bhd. Assigned to
No. 1, Persiaran Dato’ Menteri, Section 2, P.O.Box 7035, 40911 Shah Date
Alam, Selangor Darul Ehsan.

SIRIM QAS International Sdn. Bhd. Communication and Multimedia Certification Section Page 2 of 2
Issue: 1 Rev. : 0