SUPERB Application Form to Participate in the Business Challenge

Please complete this form and email it back to

superb.application@teraju.gov.my
State your email subject as: SUPERB Application : <Your Idea Title>
You can also attach any relevant additional information.
The closing date for the 1st round of applications is on 21 February 2014,
5.30pm.
Idea Title :
Personal Details
Team Leader
Name
Gender
Date of Birth
MyKad Number
Marital Status
Number of Children (if any)
Language(s) Spoken
Education/Qualification
Home Address
Mobile Number(s)
Email

:
:
:
:
:
:
:
:
:
:
:

I am a(n)

Family business background

Previous employer(s)

Student <which institution and course?>

Employee
Professional
Unemployed <how long has it been?>
Entrepreneur <how many years or how many
times?>
:
:

<Please explain business of family members, if

any>
<Please state designation and department>

Personal Details
Team Member 1
Name
Gender
Date of Birth
MyKad Number
Education/Qualification
Home Address
Mobile Number(s)
Email

:
:
:
:
:
:
:
:

I am a(n)

Student <which institution and course?>

Employee
Professional
Unemployed <how long has it been?>
Entrepreneur <how many years or how many
times?>

Family business background

Previous employer(s)

:
:

Team Member 2
Name
Gender
Date of Birth
MyKad Number
Education/Qualification
Home Address
Mobile Number(s)
Email

:
:
:
:
:
:
:
:

I am a(n)

Family business background

Previous employer(s)

<Please explain business of family members, if

any>
<Please state designation and department>

Student <which institution and course?>

Employee
Professional
Unemployed <how long has it been?>
Entrepreneur <how many years or how many
times?>
:
:

<Please explain business of family members, if

any>
<Please state designation and department>
2

Company (if already

incorporated)
Company Name
Company Number
Company Address

:
:
:

Company Shareholders

Company Directors

Paid-Up Capital (RM)

Date of Incorporation
Years in Operation
Nature of Business
Revenue for 2013
Profit after tax for 2013

:
:
:
:
:
:

<Please state name and shareholding

percentage>
<Please state name and shareholding
percentage>

Please answer the questions below regarding your

idea/product/solution:
1. Tell us your business idea in less than 200 words

2. Why do you think it will work? What makes your business unique?

3. Which sector does your business

fall into?

Communications, Content & Infrastructure

Electronics & Electrical
Wholesale & Retail
Palm Oil & Rubber
Oil, Gas & Energy
Financial Services
Business Services
Healthcare
Agriculture
Education
Tourism
Other: <state other sector(s)>

4. Has this idea been pitched or presented to other Government agencies? If yes,
which agencies?

5. How much did you invest your own money in this?

6. Tell us your team's experience and capability that makes you capable of delivering
this project.
Please include relevant past projects.

7. Who is your target market?

8. What would be your business

model?

9. How much funds do you need and why do you need it?
Utilisation of funding

Amount (RM)

TOTAL

Declaration
Have you received any financial assistance from the Government before? ( Yes /
No )
If yes, which Government agency, how much, for what type of project and state
utilisation of funds

Please state which information provided in this application that you do not
agree to be used for the purposes of consolidation, analysis, preparing
statistics, marketing, advertising and promotion via television and/or other
mass or social media
5

I, <name>, <MyKad no.>, hereby declare:

1. Acknowledgement
a) I acknowledge that the submission of this application does not create an
obligation or guarantee on the part of TERAJU to approve the application
herein.
b) I hereby agree for TERAJU to process my personal data provided herein for
the purpose of this application.
c) I hereby acknowledge that while TERAJU will use reasonable effort to
safeguard the confidentiality of the information submitted in this
application, TERAJU shall be entitled to:
i.

disclose the information submitted herein to such persons involved in

the evaluation process of this application including without limitation
TERAJUs employees, consultants, agents, advisors and/or such other
persons as may be appointed by TERAJU; and

ii.

use any information submitted herein for the purposes of

consolidation, analysis, preparing statistics, marketing, advertising
and promotion via television and/or other mass or social media, and
if I do not agree that any part of the information provided herein can
be used for such purpose, I should expressly identify such data and
highlight the same to TERAJU in advance in this application form.

d)

I further acknowledge that TERAJU considers all submitted applications as

confidential and treats all team matters accordingly. However, TERAJU
cannot guarantee complete confidentiality for proprietary matters. TERAJU
is not responsible for any proprietary information and/or intellectual
property included in a submitted application. Ultimately, I am solely
responsible to protect sensitive materials.

2.

True and Accurate

I hereby declare that all information furnished, or to be furnished, in

connection with the Project and this application does not contain any untrue
statements and were honestly provided and made upon due and careful
inquiry and I have not omitted to state any fact(s), the omission of which
makes such statements misleading.

3. Personal Data Protection Statement

I agree that, with regard to the personal data relating to the other
individual(s), which are provided to TERAJU in this application form, I have
obtained the following from such individual(s):
a his/her consent for TERAJU to process his/her personal data provided in
this application form, and any other additional personal data which may
be further provided to TERAJU in connection with this application form;
b his/her confirmation that his/her personal data provided are complete and
accurate;
c his/her acknowledgment that he/she is entitled to obtain access to and to
request correction of the personal data provided to TERAJU and that
he/she can request TERAJU to cease processing his/her personal data. For
this purpose, he/she should contact TERAJU, either by sending an email to
superb.application@teraju.gov.my or by sending a letter to TERAJU at
Level 5, Surian Tower No. 1, Jalan PJU 7/3 Mutiara Damansara, 47810
Petaling Jaya, Selangor Darul Ehsan; and
d his/her consent that TERAJU may disclose his/her personal data to:
i any TERAJU vendor(s), contractor(s) and/or outsourcing company(ies)
engaged by TERAJU, for purposes in connection with this application
form; and/or
ii Government authorities, agencies and and/or any other regulatory
body, to the extent that the Government or other authorities,
agencies and/or any other regulatory body need to know, or as
permitted by applicable laws and regulations.
I further agree that in any event TERAJU receives any request by any data
subject for withdrawal of consent to process any personal data provided
herein, TERAJU has the right to treat this application as null and void.

BY SUBMITTING THIS APPLICATION FORM TO

TERAJU, I HEREBY CONFIRM MY DECLARATION,
ACKNOWLEDGEMENT AND AGREEMENT ON ALL
THE INFORMATION GIVEN AND TERMS STATED
ABOVE