GUIDELINE FOR REGISTRATION

1 This form is to be completed by company that opted for PIKAS Common PPV.

2 Please complete company’s information in Form 1 and provide employees details in Annex
1.

3 Please email the completed form together with the signed PIKAS Terms and Conditions to
vaccine4industry@miti.gov.my.
 FORM 1

PROGRAM IMUNISASI INDUSTRI COVID-19 KERJASAMA AWAM SWASTA (PIKAS) PUSAT PEMBERIAN VAKSIN (PPV)
(FOR PIKAS COMMON PPV APPLICATION)

CONTACT PERSON DETAILS

TOTAL NUMBER OF POSITIVE
COMPANY MANUFACTURING LICENSE /
NO. COMPANY/ ORGANISATION/ AGENCY REGISTRATION ADDRESS POSTCODE STATE BUSINESS EMPLOYEES CASES (ACTIVE CASES MIDA EXEMPTION LETTER/ ANNEX
ACTIVITY PHONE NO./ (registered for AT THE TIME OF
NO. NAME PBT LICENSE REGISTRATION
EMAIL vaccination) APPLICATION)
1 Annex 1
2 Annex 2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17

Note:
1. For companies which has more than one (1) company interested in registering concurrently.
2. Location and state of the company will need to be specified to allow MITI to assign the nearest common-site PPV.
 ANNEX 1
To be filled by the companies

Company Location: ………………………………………………………………………. (e.g. Industrial Estate/ Industrial area/ industrial zone)

Details of Company: (to be completed by company for their local and foreign employees already registered for COVID-19 Vaccination Programme)
Company Name: ……………………………………………………………………………..
Company Registration No.: …………………………………………………………….
Company Address : ……………………………………………………………………………..
…………………………………………………………………………………
Postcode : ……………………………………………………………………………………
Tel No. : ………………………………………..
Contact person 1 Name : …………...……………………………
Designation:…………………………………..
H/P No.: ……………………………………….
Email Address:……………………………….

Contact person 2 Name:…………………………………………..

Designation: ……………………………………
H/P No.:………………………………………….
Email address: ………………………………….
Total head count registered under COVID-19 Vaccination Programme : ………………………….

Gender
Company Name/ Kindly indicate - 1 (for male)
No. Name No. I/C or Passport No. Employee ID Kementerian MySejahtera ID Phone No. Age
2 (for female)

DISCLAIMER

We hereby confirm that the information provided herein is accurate, correct and complete and that the documents submitted along with this application form are genuine. We undertake to inform the Ministry of International Trade and Industry (MITI) in
writing (at vaccine4industry@miti.gov.my) of any changes to the information already provided and update the information on this form whenever requested to do so by the MITI.

We hereby declare that, in the event of our information in this form will be required to be shared with other Ministries and/or agencies for the purpose of the Immunisation Programme, we explicitly agree to MITI’s full compliance to provide such information
without the need for MITI to notify us or to seek our additional consent.