Land Proposal Form - Retail Business Partnership

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Retail Land Application for PETRONAS Station

Permohonan Cadangan Tanah Peruncitan untuk Stesen PETRONAS

STEP 1 OF 3

Personal Particulars

Butiran Peribadi

Application Type

Jenis Aplikasi

Land Proposal for PETRONAS Station-$Permohonan Cadangan Tapak bagi Pembinaan Stesen PETRONAS
Application for Conversion to PETRONAS Station-$Permohonan Pertukaran ke Jenama Stesen PETRONAS

Name as per Identity Card

Nama mengikut Kad Pengenalan

Identity Card No

No Kad Pengenalan

Gender

Jantina

Male-$Lelaki
Female-$Perempuan

Race

Keturunan

Malay-$Melayu
Chinese-$Cina
Indian-$India
Others-$Lain-lain

Mobile Phone No

No. Tel. Bimbit

E-mel

Address

Alamat

City

Bandar

State/Province

Negeri/Wilayah

Postcode

Poskod

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STEP 2 OF 3

Company Particulars (if Applicable)

Butiran Syarikat (Jika Berkenaan)

Company Name

Nama Syarikat

SSM Number

No SSM

Type of Company

Jenis Syarikat

Sdn. Bhd
Enterprises

Office Number

No. Pejabat

Company Email

E-mel Syarikat

Company Address

Alamat Syarikat

State

Negeri

City

Bandar

Postcode

Poskod

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Land Address as per Land Title

Alamat Tanah mengikut Hakmilik Tanah

Township/Mukim

Perbandaran/Mukim

District

Daerah

Plot No

City

Bandar

State/Province

Negeri/Wilayah

Postcode

Poskod

Current Land Use (i.e. Petrol Land, Agriculture Land, etc)

Gunatanah Semasa (iaitu Tanah Petrol, Tanah Pertanian, dll)

Station Concept

Konsep Stesen

CODO – Company Owned Dealer Operated
DODO – Dealer Owned Dealer Operated

Picture of land/station (optional, not more than 50MB)

Gambar tanah/stesen (pilihan)

Copy of Land Title (compulsory, not more than 50MB)

Salinan Hakmilik Tanah (wajib)

GPS location (compulsory)

Lokasi GPS (wajib)

e.g. 3.1574968, 101.7115592

Declaration

Pengisytiharan

I understand that the operation of a PETRONAS service station must be in compliance with laws, regulations and the Company’s prescribed standards, policies & guidelines;
Saya memahami bahawa pengendalian stesen servis PETRONAS mestilah mematuhi undang-undang, peraturan dan piawaian, dasar & garis panduan yang ditetapkan oleh Syarikat;

I am an employee of PETRONAS / my family member is employee of PETRONAS;
Saya adalah kakitangan PETRONAS / ahli keluarga saya adalah kakitangan PETRONAS;

I have never been declared a bankrupt;
Saya tidak pernah diisytiharkan muflis;

I have never been convicted of any criminal offense;
Saya tidak pernah disabitkan dengan mana-mana kesalahan jenayah;

I shall abide by all standard requirements related to this application as specified in the Company’s retailer recruitment process;
Saya akan mematuhi semua keperluan standard yang berkaitan dengan permohonan seperti yang dinyatakan dalam proses pengambilan peruncitan Syarikat;

I have not offered any inducement to any PETRONAS employee for favorable consideration of my application or future appointment;
Saya tidak menawarkan sebarang dorongan kepada mana-mana kakitangan PETRONAS untuk pertimbangkan yang permohonan atau pelantikan saya;

I declare that I am not a Government Official
Saya mengaku bahawa saya bukan Pegawai Kerajaan

I confirm that the information I rendered above is true, complete and accurate to the best of my knowledge. I understand and accept that should any information herewith declared be false or untrue, the Company shall have the right to cancel or terminate any license, products supply etc, if any, made to me.
Saya mengesahkan bahawa semua maklumat dan kenyataan yang diberikan adalah benar, lengkap dan tepat sepanjang pengetahuan saya. Saya faham dan menerima sekiranya maklumat yang diisytiharkan sebagai palsu atau tidak benar, Syarikat berhak untuk membatalkan atau menamatkan sebarang lesen, pembekalan produk dll, jika ada, yang dibuat ke atas saya.

By submitting the application form, you confirm that:
all information provided are true and correct; and
you agree for your personal data to be processed in accordance with our Privacy Policy and Personal Data Notice for Customers.
Should you have any question on the processing of your personal data, please send an email to Mesralink or call us at call us at 1-300-88-8181 by attention to Retail Network & Real Estate Department (RNRED).
Dengan menghantar borang permohonan ini, anda mengesahkan bahawa:
semua maklumat yang diberikan adalah benar dan tepat; dan
anda bersetuju bahawa semua data peribadi diproses mengikut Polisi Privasi dan Notis Data Peribadi untuk Pelanggan.
Sekiranya anda mempunyai sebarang soalan mengenai pemprosesan data peribadi anda, sila hantar e-mel kepada Mesralink atau hubungi kami di 1-300-88-8181 dan diberi perhatian kepada Jabatan Rangkaian Runcit & Hartanah (RNRED).

Thank You

Your form has been submitted!

Terima Kasih

Permohonan anda sudah dihantar!

To check your application status, please call Mesralink at 1-300-22-8888 or email [email protected]
For any enquiries, please do not hesitate to reach out the respective Site Executive as below.

Untuk semak status permohonan anda, sila hubungi 1-300-22-8888 atau e-mel [email protected]
Untuk sebarang pertanyaan, sila hubungi Eksekutif Tapak masing-masing seperti di bawah.

Mr. Ilman ([email protected])
Selangor (Gombak, Hulu Langat, Hulu Selangor), Pahang, Terengganu, Kelantan
Mr. Ahmad Yusri ([email protected])
Selangor (Petaling, Klang, Kuala Selangor, Sabak Bernam), Perak, Pulau Pinang, Kedah, Perlis
Ms. Amelene ([email protected])
Sabah, Sarawak, WP Labuan
Ms. Syafiqah ([email protected])
Selangor (Kuala Langat, Sepang), Kuala Lumpur, WP Putrajaya, Negeri Sembilan, Melaka, Johor
Mr. Nick M Yasier ([email protected])
Site Conversion / Pertukaran Tapak
Ms. Azmahani Yaacob ([email protected])
Site Conversion / Pertukaran Tapak

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