Medivest Vendor Registration Portal

1. SERVICES CODE *

	Service Code	Service Name	Category Code	Category Name	Details Code	Details Name

2. BUSINESS TYPE **

Please tick in at least one option.

General

Manufacturer

Sole Agent/Distributor

Please upload attachment.

Agent/Distributor

Please upload attachment.

MOH Nominated Vendor

Please upload attachment.

3. BUSINESS / COMPANY DETAILS

3.1 Business / Company Name *

Business / Company Name cannot be blank.

3.2 Business / Company Registration No. *

Business / Company Registration No. cannot be blank.

3.13 SST Registration No.

3.3 Holding or Parent Company (If applicable)

3.4 Registered Address *

Registered Address cannot be blank.

3.5 Correspondence Address (If differs from above)

3.6 Office Telephone Number *

Office Telephone Number cannot be blank.

3.14 Contact Person(s) H/P No. *

Contact Person(s) H/P No. cannot be blank.

3.7 Office Facsimile Number

3.8 Email Address *

Email Address cannot be blank.

3.9 Alternative Email Address

Alternative Email Address cannot be blank.

3.10 Company Type *

Company Type cannot be blank.

3.11 Date of Incorporation / Registration *

Date of Incorporation / Registration cannot be blank.

3.12 Website

3.15 Signboard Premise (jpeg. png. tiff.) *

Please upload attachment.

4. SHAREHOLDER AND BOARD OF DIRECTORS DETAILS

4.1 Malaysian

Maximum 100%

4.2 Foreign

Maximum 100%

4.3 Status

Status cannot be blank.

4.4 Details of Sole Proprietor / Partner / Shareholder *
(Please attach relevant forms where applicable)

	Name	NRIC No.	Amount (RM)	Percentage

4.5 Details of Board of Directors *
(Member of Board (Sdn Bhd or Berhad))

	Name	NRIC No.	Citizenship

5. STAFFING INFORMATION **

Please fill in at least one category.

No.	Category	Total
1	Management
2	Professional (Diploma and above)
3	Skilled Personel (Competent Personal) >= 3 years experience
4	Skilled Personel (Competent Personal) < 3 years experience
5	Administration
6	Foreign workers
Total		0

6. FACILITIES **

Please fill in at least one type.

No.	Type	Owned	Rental
1	Office Premise
2	Factory
3	Workshop
4	Transportation

7. TECHNOLOGIES

Please specify if you have the technology (e.i. Robotic, I.O.T, system or etc)

	No	Technology	Description

8. COMPANY'S REGISTRATION

Registered as supplier/vendor/manufacturer with ministries, government departments or private sectors.
(Please tick the appropriate box & please attach the photocopy of registration.)

a. CIDB

	No	Class	Category	Specialization	Registration No.	Date of Registration	Expiry Date	Attachment

b. Ministry of Finance (MOF)

Gred

c. Pusat Khidmat Kontraktor (PKK)

	No	Registration Certificate No.	Registration Gred	Category	Validity Period	Attachment

d. Energy Commission (ST)

	No	Certificate No.	Type of Form	Name of Certificate Owner/Company	Expiry Date	Attachment

E. Medical Device Authority (MDA) - If Applicable

i. Medical Device Registration Certificate
- Section 5 (1) of Act 737

	No	Serial No	Registration No	Registration Validity Date	Medical Device Name	Class	Brand	Product Identifier	Attachment

ii. Establishment License
- Section 24 (1) of Act 737

	No	Serial No	License No	License Validity Date	Person Responsible	Attachment

9. STATUTORY, REGULATORY AND ACCREDITATION.

9.1 List of Statutory and Regulation Compliance

(i.e International Air Transport Association (IATA), Jabatan Bekalan Electric (JEE), Kementerian Dalam Negeri (KDN), Kementerian Kesihatan & Malaysian Medical of Association (MMA), Lesen Pengangkutan Jalan (JPJ), Lembaga Perlesenan Kenderaan Perdagangan (LPKP), Malaysian Communication & Multimedia Commission (MCMC))

	No	List of statutory and regulation compliance	Validity Period	Expiry Date

9.2 Certificate/Registration with Professional Bodies

(i.e Board of Architects (BOA), Board of Engineers Malaysia (BEM), Board of Quantity Surveyor (BQS), Lembaga Jurukur Tanah Malaysia (LJTM), Persatuan Insurance Am Malaysia (PIAM))

	No	List of Certificate/Registration with Professional Bodies	Date

9.3 Management System (ISO)

	No	List of Management System (ISO)	Yes/No	Expiry Date
	1	ISO 19001 Quality Management System
	2	ISO 14001 Environmental Management System
	3	ISO 45001 Occupational, Health & Safety Management System

9.4 Award and Recognition

	No	List of Award and Recognition

10. EXPERIENCE OF WORKS / SERVICES

10.1 Current Project **

Please specify current job/contract

	No	Clients' Name	Title of Contract	Commencement Date	Expiry Date	Total Contract Sum (RM)

10.2 Completed Project **

Please specify past job/contract undertaken in the past 3 years

	No	Clients' Name	Title of Contract	Commencement Date	Expiry Date	Total Contract Sum (RM)

10.3 Medivest and Other Concession Company

Please specify current & past experience

	No	Clients' Name	Title of Contract	Commencement Date	Expiry Date	Total Contract Sum (RM)

11. CREDIT/PAYMENT TERM

Medivest Payment Term - 60 days from the date of receipt undisputed invoice & its relevant supporting document.

12. COMPANY's FINANCIAL INFORMATION

12.1 Capital / Equity *

Accumulate Capital (RM)

(For Partnership and Sole Enterprise)

Authorized Capital (RM)

(For Sdn Bhd or Berhad)

Paid-Up Capital (RM)

(For Sdn Bhd or Berhad)

12.2 Bank *

Bank cannot be blank.

12.3 Bank Account No.*

Bank Account No. cannot be blank.

12.4 Bank Account Name*

Bank Account Name. cannot be blank.

12.5 Banker's Address *

Banker's Address cannot be blank.

12.6 Financial Facilities

	Name of Bank	Address	Type of Facility	Amount

13. FINANCIAL INFORMATION **

Please fill in at least one indicator.

No.	Indicator	Amount (RM)
1	Paid-up /Accumulated Capital
2	Turnover : Revenue
3	Profitability : Profit before tax (PBT)
4	Shareholders' Fund (Shareholders' Equity)
5	Current Cash and Cash Equivalent Balance : Cash & Bank Balance
6	Debt to Equity Ratio (Total Debt/Total Asset)	Maximun value is 3
7	Working Capital Ratio (Current Asset/Current Liabilities)	Maximun value is 3
8	Current Bank Balance (Averange 3 months)

14. GEOGRAPHICAL AREA OF SERVICES **

Please tick at least one option.

Kuala Lumpur & Selangor

Negeri Sembilan

Melaka

Johor

Other than the above-mentioned

15. NAME OF PERSON LEGALLY EMPOWERED TO ACT FOR YOUR COMPANY *

	No	Name	Position	Telephone No.

16. DECLARATION *

I/We read, understood and agreed on the following Policy as attached in the email:

16.1 PERSONAL DATA PROTECTION NOTICE

Please agree 16.1 PERSONAL DATA PROTECTION NOTICE

Please upload attachment.

16.2 ANTI BRIBERY AND ANTI CORRUPTION (ABAC)

Please agree 16.2 ANTI BRIBERY AND ANTI CORRUPTION (ABAC)

Please upload attachment.

16.3 CONFLICT OF INTEREST (COI)

Please agree 16.3 CONFLICT OF INTEREST (COI)

Please upload attachment.

SUPPORTING DOCUMENT TO BE ATTACHED
** Note :
1. You may attach more than one document in each field
2. You may upload PDF, Excel, JPEG,Microsoft word,PNG,Power Point

Attachment(s)

A.1 Company Profile

A.2 SSM Company Profile*(upload full pages of SSM e-info)*

A.3 Form 9 / Form 8 / Form A / Form 13 / Section 17 - Company Registration

A.4 Form 24 / Section 78 / Section 51 - Return of Allotment of Shares

A.5 Form 44 / Section 46 (3) - Registered Office

A.6 Form 49 / Section 14 / Section 58 - Director's Details

A.7 Form 32A - Change of Shareholder of company

A.8 Form E

A.9 Form D

A.10 Business Information & Current Owner (Enterprise/Partnership/Sole Proprietor)

A.11 Oversea Certificate of Registration

A.12 Memorandum for Article (M&A) / Constitution

A.13 Detail of Experience

A.14 ISO Certificate

A.15 Statutory and Regulation Compliance

A.16 Certificate/Registration with Professional Bodies

A.17 Latest Audited Account for Sdn Bhd & Berhad

A.18 Latest 1 year Certified Management Account for Enterprise, Partnership & Sole Proprietor

A.19 Latest 3 months Bank statements

A.20 SST Registration (if any)

Name of Company :

Mailing Address :

Type of Company :

Telephone No. :

Email :

CIDB Registration No :

SSM Registration No & Others :

Service Code :

Vendor Summary Evaluation

No	Scope	Maximum Score		Vendor Score
		Score (Point)	Score (%)	Score (Point)	Score (%)
		(a)	(b)	(c)	(d= c/a xb)
1	Corporation	10	10	0	0
2	Technical Capabilities	25	25	0	0
3	Business Track Record	25	25	0	0
4	Statutory, Regulatory and Accreditation	10	10	0	0
4.5	Technical Evaluation	70	70	0	0
5	Financial Capabilities	100	30	0	0
5.5	Evaluation Marks	170	100	0	0

SCOPE 1: CORPORATION

Point Scores

1A. Total years Incorporated

1B. Register with CIDB

1C. Registered with Ministry of Finance (MOF)

1D. Registered with PKK Bumiputera

Vendor Score (%) for Corporation : 0

Maximum Score (%) for Corporation : 10

SCOPE 2: TECHNICAL CAPABILITY

Point Scores

2A. Business Status

2A. Business Status cannot be blank.

2B. No of Professional Staff ( Diploma and above)

2C. No. of Skilled Personnel (Experience > 3 years)

2D. No of Facilities

2Di. Office Premise

2Dii. Factory

2Diii. Workshop

2Div. Transportation

2E. Do you have any technology

Vendor Score (%) for Technical Capabilities : 0

Maximum Score (%) for Technical Capabilities : 25

SCOPE 3: BUSINESS TRACK RECORD

Point Scores

3A. Number past 3 years completed Project over RM300K

3B. No. of Current/On-going Project

3C. Project with Medivest or/and Concession Companies

3D. Number of project with Medivest

3D. Number of project with Medivest cannot be blank.

3E. Last Project completed for Medivest

3E. Last Project completed for Medivest cannot be blank.

Vendor Score (%) for Business Track Record : 0

Maximum Score (%) for Business Track Record : 25

SCOPE 4: STATUTORY, REGULATORY AND ACCREDITATION

Point Scores

4A. List of Statutory and Regulatory Compliance 0

4B. List of Certificate/Registration other than No.8/Professional 0

4C. Register/ Certification with ISO 0

Vendor Score (%) for Statutory, Regulatory and Accreditation : 0

Maximum Score (%) for Statutory, Regulatory and Accreditation : 10

Maximum Score (%) for Technical Evaluation : 70

SCOPE 5: FINANCIAL CAPABILITY

Point Scores

5A. Status of company SME
Definition of SME : Business that maintain revenues, assets or a number of employee below a certain threshold.
Manufacturing sector: sales turnover not exeeding RM50Mil @ full time employee not exceeding 200.
Services & other sector: sales turnover not exceeding 20Mil @ full time employee not exceed 75

5A. Status of company SME cannot be blank.

5B. Categorised of SME under Manufacturing sector
Medium : sales turnover from RM15Mil ≤ to RM50Mil @ full time employee from 75 ≤ 200
Small : sales turnover from RM300K < to RM15Mil @ full time employee from 5 < 75
Micro : sales turnover < RM300K @ full time employee < 5

5B. Categorised of SME cannot be blank.

5C. Shareholding structure

5C. Shareholding structure cannot be blank.

5D. Submit latest Audited/Management Account

5D. Submit latest Audited/Management Account cannot be blank.

5E. Submit 3 months Bank Statement

5E. Submit 3 months Bank Statement cannot be blank.

5F. Paid-up Capital

5G. Turnover : Revenue

5H. Profitability : Profit before tax (PBT)

5I. Shareholders' Fund (Shareholders' equity)

5J. Current Cash and Cash Equivalent Balance : Cash & Bank Balance

5K. Debt to Equity Ratio (Total Debt/ Total Assets)

5L. Working Capital Ratio (Current Asset/Current Liabilities)

5M. Current Bank Balance (Average 3 months)

5A. Status of company Non-SME
Defination of Non-SME : other than criteria of SME companies

5A. Status of company Non-SME cannot be blank.

5B. Shareholding structure

5B. Shareholding structure cannot be blank.

5C. Submit latest Audited/Management Account

5C. Submit latest Audited/Management Account cannot be blank.

5D. Submit 3 months Bank Statement

5D. Submit 3 months Bank Statement cannot be blank.

5E. Paid-up Capital

5F. Turnover : Revenue

5G. Profitability : Profit before tax (PBT)

5H. Shareholders' Fund (Shareholders' equity)

5I. Current Cash and Cash Equivalent Balance : Cash & Bank Balance

5J. Debt to Equity Ratio (Total Debt/ Total Assets)

5K. Working Capital Ratio (Current Asset/Current Liabilities)

5L. Current Bank Balance (Average 3 months)

Vendor Scores (%) for Financial Capabilities :

Maximum Score (%) for Financial Capabilities : 30

Vendor Total Scores (%) for Vendor Registration System (VRE) : 0

Maximum Score (%) for Vendor Registration Evaluation (VRE) : 100

STAR For VENDOR REGISTRATION EVALUATION (VRE) : 0

LEGEND For VENDOR REGISTRATION EVALUATION (VRE) :

Please bank in the Vendor Registration Fee amounting RM100 to the following account

Details of Medivest Bank Account for the Vendor Registration.

Bank : Malayan Banking Berhad

Account Name : Medivest Sdn Bhd

Account Number : 5643 2460 8028

Amount : RM100 only

Payment Reference : VRA (Company Name)

Attach the payment slip

Please upload attachment.

Approval Audit Trail

	Approver	Action By	Action Date	Status	Remarks	Approval Level

Vendor Registration []

1. SERVICES CODE *

2. BUSINESS TYPE **

3. BUSINESS / COMPANY DETAILS

4. SHAREHOLDER AND BOARD OF DIRECTORS DETAILS

5. STAFFING INFORMATION **

6. FACILITIES **

7. TECHNOLOGIES

8. COMPANY'S REGISTRATION

a. CIDB

b. Ministry of Finance (MOF)

c. Pusat Khidmat Kontraktor (PKK)

d. Energy Commission (ST)

E. Medical Device Authority (MDA) - If Applicable

9. STATUTORY, REGULATORY AND ACCREDITATION.

9.1 List of Statutory and Regulation Compliance

9.2 Certificate/Registration with Professional Bodies

9.3 Management System (ISO)

9.4 Award and Recognition

10. EXPERIENCE OF WORKS / SERVICES

10.1 Current Project **

10.2 Completed Project **

10.3 Medivest and Other Concession Company

11. CREDIT/PAYMENT TERM

12. COMPANY's FINANCIAL INFORMATION

13. FINANCIAL INFORMATION **

14. GEOGRAPHICAL AREA OF SERVICES **

15. NAME OF PERSON LEGALLY EMPOWERED TO ACT FOR YOUR COMPANY *

16. DECLARATION *

SUPPORTING DOCUMENT TO BE ATTACHED ** Note : 1. You may attach more than one document in each field 2. You may upload PDF, Excel, JPEG,Microsoft word,PNG,Power Point

Vendor Summary Evaluation

SCOPE 1: CORPORATION

SCOPE 2: TECHNICAL CAPABILITY

SCOPE 3: BUSINESS TRACK RECORD

SCOPE 4: STATUTORY, REGULATORY AND ACCREDITATION

SCOPE 5: FINANCIAL CAPABILITY

Approval Audit Trail

SUPPORTING DOCUMENT TO BE ATTACHED
** Note :
1. You may attach more than one document in each field
2. You may upload PDF, Excel, JPEG,Microsoft word,PNG,Power Point