JK GILL PLT (LL0021993-LGN)
No. 18A, Lorong Pending 4A, Bandar Puteri, 41200 Klang, Selangor Darul Ehsan.
Tel/Fax: 03-38847383 E-mail: marketing@jkgillwaste.com Website: www.jkgillwaste.com
APPLICATION FORM
Clinic Name
Company Name
Co Registration No GST NO
Address
Telephone No : HP No :
Email ID :
Sole
Type Of Business Partnership Sdn Bhd Or Bhd
Proprietorship
GP
DENTIST HOSP/LAB VET
CLINIC
Nature Of Business
TCM COMPANY OTHERS
Name Of Application
NRIC
Designation In Company Shareholder : YES / NO
Particular Of Shareholders
Name NRIC / Passport No Home Address
Submit Photocopies of :
• Business SSM Certificate / License (proof of business registration).
• Latest Annual Practising Certificate (APC) if applicable to your industry).
• NRIC (for individual application/partners/directors).
• For SDN BHD / BHD Companies :
i . Form 9 (Return of Allotments of Shares).
ii. Form 24 (Notice of Change of Directors / Secretary).
iii. Form 49 (Register of Directors / Managers / Secretaries).
I/we agree to the above terms and conditions and wish to open an account and certify that all the
information given is true and correct
CUSTOMERS OFFICIAL STAMP
Authorised Signature
Name :
Designation :
Date :
Page 1 of 2
JK GILL PLT (LL0021993-LGN)
No. 18A, Lorong Pending 4A, Bandar Puteri, 41200 Klang, Selangor Darul Ehsan.
Tel/Fax: 03-3884 7383 E-mail: marketing@jkgillwaste.com Website: www.jkgillwaste.com
PLEASE TICK THE BOX BELOW
Package : A B C KG
COMMENCEMENT DATE
( DD/MM/YYYY)
Payment Terms Cash Online Cheque
*Note : All online & cheque payments must be done within 14 days from the date of invoice issued
Collection Type : Monthly 2 Month Once Fix Remarks :
Additional Orders
2.5 Liter Sharp Bin 30 Liter Pedal Bin LDPE Bag 400 X 500 ( 10ltr - 100pcs )
5 Liter Sharp Bin 40 Liter Pedal Bin LDPE Bag 600 x 550 ( 18ltr - 50pcs )
10 Liter Sharp Bin 120 Liter Wheel Bin LDPE Bag 600 x 980 ( 30/4ltr - 50pcs )
20 Liter Sharp Bin 240 Liter Wheel Bin LDPE Bag 800 x 900 ( 120ltr - 50pcs )
10 Liter Pedal Bin 660 Liter Wheel Bin
18 Liter Pedal Bin Cable Tie ( 100 pcs )
OPERATION HOURS AM / PM LUNCH HRS
MONDAY TO TO
TUESDAY TO TO
WEDNESDAY TO TO
THURSDAY TO TO
FRIDAY TO TO
SATURDAY TO TO
SUNDAY TO TO
PUBLIC HOLIDAY TO TO
Key Terms & Conditions
Compliance & Restrictions
• Non-transferable Credit : Credit terms apply only to the approved entity, not sister / associate companies.
• Mandatory Updates : Notify JK GILL PLT within 14 days of changes to ownership, address,
signatories, or business nature.
• Payment Terms : Invoices must be settled within 14 days of invoice.
Penalties & Liabilities
• Late Payment : 2% monthly interest on invoices unpaid for over 60 days (rate subject to change).
• Personal Guarantee : Directors / Partners/ Officers assume joint liability for unpaid debts.
• Legal Action : Failure to pay may result in legal proceedings, with the company liable
for collection costs, legal fees, and litigation expenses.
Rights of JK GILL PLT
• Credit facilities may be suspended or withdrawn with valid reasons.
I/we agree to the above terms and conditions and wish to open an account and certify that all the
information given is true and correct .
CUSTOMERS OFFICIAL STAMP
Authorised Signature
Name :
Designation :
Date :
FOR OFFICE USE ONLY
Receive Date Zone
Clinic Registration Code Person In Charge
Sales Person Date
Page 2 of 2
Bahagian Perlesenan Buangan Terjadual TWG/SBT/99-2
Jabatan Alam Sekitar (sila isi dalam lima salinan)
Kementerian Sumber Asli dan Alam Sekitar
Aras 1-4, Podium 2&3, Wisma Sumber Asli
No.25, Persiaran Perdana, Presint 4,
62574 Putrajaya.
Tuan,
PENGESAHAN PENGGUNAAN PREMIS *PEMEROLEHAN KEMBALI & KONTRAKTOR PENGANGKUT
Saya dengan ini mengesahkan syarikat/kilang kami iaitu __________________________________________
menghasilkan Sisa Klinikal (SW 404) berjumlah kg. sebulan.#
Sehubungan dengan ini pihak kami bersetuju melantik Edgenta Mediserve Sdn. Bhd. bagi mengangkut buangan
tersebut untuk dihantar ke premis penerima buangan iaitu:-
Nama premis: Jenis buangan yang dihantar
Loji pelupusan sisa klinikal Edgenta Mediserve Sdn Bhd i. Sisa Klinikal
Alamat premis: Lot 65, Jalan Logam 3,
Kamunting Raya Industrial Estate
34600 Taiping, Perak
No. lesen: 004185 (pengangkutan)
004184 & 003498 (penggunaan premis penunu buangan terjadual)
2. Saya mengakui dan mengesahkan bahawa maklumat yang dinyatakan di atas adalah benar dan sah.
Pegawai yang bertanggungjawab Saksi
Nama: Nama:
Jawatan: Jawatan:
No. K/P: No. K/P:
Tarikh: Tarikh:
Tandatangan Tandatangan
Cop rasmi Cop rasmi
Syarikat Syarikat
Nota: * Potong yang tidak berkenaan
# Gunakan lampiran jika perlu
Untuk kegunaan Jabatan Alam Sekitar
Diluluskan/tidak diluluskan
b.p Ketua Pengarah Alam Sekitar Tarikh:
