MTDC Technology Incubator Application Form

APPLICATION FORM - TECHNOLOGY INCUBATION CENTRE

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MTDC TECHNOLOGY CENTRES

Centre:

SECTION A - Particulars of Company

Category:

Company Name:

Registration No.:

Correspondence Address:

Postcode:

State:

Website:

Date of Incorporation:

Date of Operation:

1. Contact Person

Name	Designation	Email	Telephone	Mobile No.

2. Staff Strength

Year	Management Staff	Technical Staff	Staff to be based at Technology Centre

3. Company Background

Summarise the nature of business in a paragraph:

Other Related Company (Branches, Subsidiaries, Group etc):

SECTION B - Capital Structure

1. Paid Up Capital (RM)

2. Structure of Shareholding

Nationality	Status	No. Of Shares (RM)	%
Malaysian	Bumiputera
Malaysian	Non-Bumiputera
Foreign
Specify Foreign Country (if applicable)
Total

3. Shareholders

Shaholder's Name	Nationality	No. of Shares (RM)	%

4. Parent Company (If applicable)

5. Board of Directors

Name	Nationality	Address

6. Financial Institutions

Banker	Account Number

SECTION C - Business Activities

Summary of Current Core Activities:

Development Plans for the next three years:

Year	Development Plans

Collaborations with universities or research institutes:

University/Research Institute	Project Title	Collaborator Name	Project Milestone	Supporting Document (MOU/MOA/Letter)

SECTION D - Business Income and Customers

Annual Sales Turnover

Current Year (RM)

Next Projection (RM)

1. Other source of financing/funding

Type	RM
Grant
Loan
Shareholder Advance
Others
Total

2. Main Customers

Please specify current projects or activities:

Customer	Current Projects or Activities

SECTION E - Required Office Space

Type of Space Required

Enterprise (>1000 sq ft)

Tech Garage (<1000 sq ft)

Purpose of having space

Administration Office

Laboratory

Production

Block Name/ Unit No.

Size of Space (sq ft)

Expected Move in Date

SECTION F - MTDC Services

Which of the service(s) will you need to assist your management?

Automation and Digitalisation (co9P)

Business Development Advisory

Financial Advisory

Fund Raising Advisory

Internship Program

Marketing Advisory

Training by TENTRA