Agent Application

New Agent Registration

Nota: Label * menandakan maklumat ini mesti diisi

Agent Particular

* Agent Category

* Agent Name

* Identification No/ Passport No

* Email

* Contact No

* Office No

* Official Address 1 (Malaysia)

* Official Address 2 (Malaysia)

* Postcode

* State

* City

* Official Address 1 (Origin country)

* Official Address 2 (Origin country)

* Postcode

* Country

* State

* City

Official Address 1 (Company)

Official Address 2 (Company)

Postcode

Country

State

City

* Bank Name (MALAYSIA)

* Account No

* Bank Address (MALAYSIA)

* Postcode

* State

* City

Attachments

DOCUMENT ATTACHMENTS

No	Document	Document Upload
1	Company Registration Certificate	Document Upload (PDF Only)*
2	Company Profile	Document Upload (PDF Only)*
3	Passport Copy	Document Upload (PDF Only)*
4	UNISEL Payment Receipt (RM100 registration fee)	Document Upload (PDF Only)*
5	Bank Account Statement	Document Upload (PDF Only)*

Agent Declaration

I/We hereby declare that the particulars and information furnished in this application form are true and accurate. I/We understand that if any information given is found to be false will lead to automatic cancellation and are subjected to approval wholly by the Universiti Selangor (UNISEL).

Company Official Stamp :*

Date :

19/04/2025

Agent Application