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Flagship Programme Application Form

FLAGSHIP PROGRAMME APPLICATION FORMBORANG PERMOHONAN PROGRAM FLAGSHIP

Untuk kegunaan pejabat sahaja / For official use only

Tarikh terimaDate of Receipt

No. RujukanReference No.

Pegawai yang memprosesProcessing officer

Peringatan / Reminder:

Semua maklumat yang dikehendaki dalam borang permohonan ini hendaklah dilengkapkan.All the information required in the application forms must be provided.

Permohonan yang tidak lengkap atau tidak layak tidak akan dipertimbangkan permohonannya.Incomplete or ineligible applications will not be entertained.

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A. BIDANG PENYELIDIKAN (PILIH SALAH SATU) /RESEARCH AREA (SELECT ONE):

BIODIVERSITY (sustainable utilisation and conservation)

CYBERSECURITY (Information security and autonomous system)

ENERGY SECURITY (Harnessing alternative resources and improving the efficient use of energy especially in the areas of renewable energy )

ENVIRONMENT AND CLIMATE CHANGE (Ecosystem management, protection and improvement to mitigate flood, drought & air pollution; Eco-tourism )

FOOD SECURITY (Improvement of food crops & animal feedstock; Exploitation of biodiversity for novel food/feed; Post harvest physiology & technology Production System and Precision Agriculture)

MEDICAL AND HEALTHCARE (Diagnostic, prevention and treatment to enable the ability to mitigate the burden of lifestyle diseases; new and emerging diseases; Cancer)

PLANTATION CROPS AND COMMODITIES (Iincreasing the productivity and utilization, focusing on Oil Palm, Timber, Rubber & Pepper)

TRANSPORT AND URBANISATION (Enabling the use of alternative energy sources and energy efficiency vehicles for environmental friendly transport; Design and engineering in vehicle, infrastructure, systems and facilities;Efficient urban waste management (Reuse, recycle & reduce))

WATER SECURITY (Sustainable sources and processing, treatment & distribution of water)

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B. BIDANG KEUTAMAAN / PRIORITY AREAS:

C. Maklumat Projek / Project Details:

i. Tajuk Projek / Project Details:

ii. Ringkasan Projek / Project Summary:

iii. Cadangan Tempoh Projek (bulan) / Proposed Project Duration (months):

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iv. Cadangan Lokasi Projek (Alamat Lengkap )/Proposed Project Location (Complete Address):

D. Aspek Teknikal / Technical Aspects:

i. Latar belakang penyelidikan dan Pembuktian konsep / Background Research and Proof of Concept

ii. Objektif Projek / Project Objective

iii. Metadologi / Methodology

iv. Hasil Projek / Project Deliverables

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v. Keperluan Pematuhan Peraturan dan Piawaian /Regulatory and Standards Compliance Requirements

vi. Hasil yang boleh dipatenkan / Patentable output

vii. Risiko Projek / Project Risks

Teknologi/ Technology : Low / Medium / High

Kewangan/ Financial : Low / Medium / High

Masa/ Time : Low / Medium / High

viii. Carian Paten Terdahulu / Prior Art Search

ix. Manfaat Projek / Project Benefits

Sosial / Social

Ekonomic / Economic

Lain –lain / Others

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x. Milestone dan Aktiviti Projek/ Project Milestones and Activities

Sila senaraikan milestone utama bagi mencapai semua objektif projek di dalam jadual di bawah dan perincikan aktiviti-aktiviti utama bagi setiap milestone. Kesemua milestone dan output yang dinyatakan mestilah boleh diukur. Jumlah kos milestone perlu bersamaan dengan jumlah kos projek yang dipohon.

Please list the major milestones to achieve all project objectives of the project in the table below and outline the major activities of each milestone. All milestone and outputs identified must be tangible. The overall milestone cost should be equal to the total project costs

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xi. Carta Gantt Projek / Project Gantt Chart(Sila lampirkan/ Please attach)

E. Kos Projek / Project Costing

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Milestone/

Milestone

Aktiviti /

Activities

Ahli Projek Yang

Terlibat / Team

Member Involve

Hasil / Deliverables

/ Output

Tarikh Pencapaian /

Completion Date

Kos (RM) /

Cost (RM)

1. Pilot plant i)ii)iii)

i)

ii)

iii)

i)ii)iii)

2.

3.

4.

5.

6.

JUMLAHTOTAL


NoKomponen /

Component

Anggaran Kos /

Estimated Cost (RM)

Kos Dipohon /

Amount Applied (RM)

Jumlah /

Total

(RM)

A

Loji Perintis/ Prototaip – peralatan dan infrastruktur sokongan sahaja

Pilot Plant/ Prototype – equipment and supporting infrastructure only

(Tidak boleh melebihi 40% kos projek/Cannot exceed 40% of total project cost)

i) RMRM

ii) RM

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NoKomponen /

Component

Anggaran Kos /

Estimated Cost (RM)

Kos Dipohon /

Amount Applied (RM)

Jumlah /

Total

(RM)

Perincian peralatan yang akan dibeli/ Detail of equipments to be purchased

Perincian peralatan sedia ada / Detail of existing equipments

NoKomponen /

Component

Anggaran Kos /

Estimated Cost (RM)

Kos Dipohon /

Amount Applied (RM)

Jumlah /

Total

(RM)

B Kajian Pra-Klinikal, Klinikal atau Lapangan/ Pre-Clinical, Clinical or Field Trial

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Peralatan / Equipment

*Model/ Model

*Buatan / Make

Kapasiti /

Capacity

Lain-lainSpesifikasi /

Other Specification

Tujuan / Purpose

Justifikasi / Justification

i)

ii)

iii)

iv)

Peralatan / Equipment

*Model/ Model

*Buatan / Make

Kapasiti /

Capacity

Lain-lainSpesifikasi /

Other Specification

Tujuan / Purpose

Justifikasi / Justification

i)

ii)

iii)

iv)


NoKomponen /

Component

Anggaran Kos /

Estimated Cost (RM)

Kos Dipohon /

Amount Applied (RM)

Jumlah /

Total

(RM)

i) RMRM

ii) RM

C

Penyediaan dan Pendaftaran IP (tidak termasuk penyelenggaraan) – existing and new

IP Preparation and Registration (excluding maintenance)

i) RMRM

ii) RM

D Kajian Pasaran / Market Testing / Market Assessment

i) RMRM

ii) RM

E Pematuhan Peraturan dan Piawaian/ Regulatory and Standards Compliance

i) RM

RM

ii) RM

FPerbelanjaan Bagi Perkhidmatan / Expenditure For Services

(Tidak boleh melebihi 20% kos projek/Cannot exceed 20% of total project cost)

i) Perundingan/ Consultancy

RM

RMii) Ujian/ Testing

RM

GPerbelanjaan Kontrak (Bagi Institut Pengajian Tinggi dan Institut Penyelidikan sahaja)

Contract Expenditure (For Institution of Higher Learning and Research Institute

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NoKomponen /

Component

Anggaran Kos /

Estimated Cost (RM)

Kos Dipohon /

Amount Applied (RM)

Jumlah /

Total

(RM)

only)

i) Pegawai Penyelidik/Research Officer RM RM

H

Perjalanan dan Pengangkutan (Bagi Institut Pengajian Tinggi dan Institut Penyelidikan sahaja)

Travel and Transportation (For Institution of Higher Learning and Research Institute only)

I Bahan Mentah/ Consumables

RMRM

RM

J Sewaan/ Rentals

RMRM

RM

K Perolehan Teknologi/ Technology Acquisition (jika berkenaan/ if applicable)

i) Perolehan Terus/Outright Acquisition RM

RMii) Kos Perlesenan/

Licensing Cost RM

iii) Latihan/ Training RM RM

JUMLAH/ TOTAL (A+B+C+D+E+F+G+H+I+J+K) RM

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Cadangan Sumber Pembiayaan/ Proposed Source of Funding

Sumber /Source RM %

Anggaran Pembiayaan Dari MOSTIEstimated Funding From MOSTI

Pinjaman BankBank Loan

Pendahuluan Pemegang SyerShareholder Advance

Lain-lain (Modal Teroka dll.)Others (Venture Capital etc.)

JUMLAHTOTAL

F. MAKLUMAT PEROLEHAN IP/ TEKNOLOGI (JIKA BERKENAAN)INFORMATION ON IP/ TECHNOLOGY ACQUISITION (IF APPLICABLE)

i. Tajuk IP/ Teknologi IP / Technology Title

ii. Penerangan IP / TeknologiIP / Technology Description

iii. No. Pendaftaran IP / Teknologi dan Tarikh LuputIP/ Technology Registration No. and Expiry Date

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iv. Pemberi IP / TeknologiIP / Technology Provider

v. Negara Asal IP / TeknologiIP / Technology Country of Origin

vi. Penerangan Latihan IP / TeknologiDetails of IP / Technology To Be Acquired

vii. Keaslian IP Novelty of IP

viii. Cadangan tarikh perolehan IP/ TeknologiProposed IP / Technology Acquisition Date

G. MAKLUMAT ENTITI / ENTITY INFORMATION

i. Klasifikasi Entiti / Entity Classification

IndividuIndivdual

Syarikat Bersaiz SederhanaMedium Sized Company

Syarikat Milik PerseoranganSole Proprietor

Agensi STISTI Agency

Syarikat MikroMicro Company

Institut Pengajian TinggiInstitution of Higher Learning

Syarikat KecilSmall Company

Institut PenyelidikanResearch Institute

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NGO BerdaftarRegistered NGO

Koperasi BerdaftarRegistered Cooperative

Pertubuhan KomunitiCommunity Group

Jawatankuasa Keselamatan dan Kemajuan KampungVillage Security and Development Committee

ii. Nama Entiti / Name of Entity

iii. Alamat Surat Menyurat / Correspondence Address

iv. Nombor Telefon / Telephone Number

v. Nombor Faks / Fax Number

vi. Tarikh Diperbadankan (jika berkenaan) / Date of Incorporation (if applicable)

vii. Modal Dibenarkan (Bagi Syarikat)/ Authorised Capital (For Company)

viii. Modal Berbayar (Bagi Syarikat)/ Paid Up Capital (For Company)

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ix. Struktur Pemegang Syer/ Shareholder Structure

Kerakyatan Bil. SyerNo. of Shares %

MalaysiaMalaysian

BumiputeraBumiputera

Bukan BumiputeraNon-Bumiputera

AsingForeign

JUMLAH/ TOTAL

x. Senarai Pemegang Syer/ List of Shareholders

Nama Pemegang SyerName of Shareholder

KerakyatanNationality

No. Kad Pengenalan/ No. Pasport/ No. Kad Pengenalan TenteraIdentification Card No./ Passport No./ Military Identification Card No.

Bil. SyerNo. of Shares

%Biasa/

CommonPilihan/

Preferred

xi. Senarai Lembaga Pengarah/ List of Board of DirectorsNamaName


AlamatAddress

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xii. Bidang Utama / Core Business

xiii. Syarikat Induk (jika berkenaan)/ Parent Company (if applicable)

xiv. Alamat Syarikat Induk (jika berkenaan) / Parent Company Address (if applicable)

xv. Senarai subsidiari atau syarikat berkaitan / List of Any Subsidiary or Related Company

xvi. Apakah produk atau servis perniagaan yang ditawarkan? / What is the Business Product or Service Offered?

H. MAKLUMAT KETUA PROJEK / PROJECT LEADER INFORMATION

NamaNameNo. Kad Pengenalan Identification Card No.

Jawatan Dalam Syarikat/Entiti

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Position in Company/ Entity

No. Telefon (Pejabat dan Bimbit)Telephone No. (Mobile and Office)

EmelEmail

I. MAKLUMAT KETUA PENYELIDIK / LEAD RESEARCHER INFORMATION

NamaName

No. Kad Pengenalan Identification Card No.

JawatanPosition

No. Telefon (Pejabat dan Bimbit)Telephone No. (Mobile and Office)

EmelEmail

J. MAKLUMAT AHLI PROJEK / DETAILS OF PROJECT MEMBERS Senaraikan dan lampirkan sesalinan CV bagi setiap ahli projek. Dokumen tersebut perlu mengandungi maklumat keupayaan teknikal dan pengurusan, kelayakan, pengalaman setiap ahli yang terlibat, maklumat penerbitan (jika ada) dan peranan ahli di dalam projek ini.

List out and attach the CVs of all project members. The CVs must contain the details of technical and management capabilities, qualification, experience of the project members, publications (if any), and role of each project members to the project.

K. MAKLUMAT KOLABORATOR /COLLABORATOR INFORMATION

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i. Klasifikasi KolaboratorSyarikat Milik PerseoranganSole Proprietor

Syarikat Bersaiz Sederhana/ BesarMedium/ Large Sized Company

Syarikat MikroMicro Company

Syarikat Senarai AwamPublic Listed Company

Syarikat KecilSmall Company

Syarikat Berkaitan KerajaanGovernment Linked Company

Institusi Pengajian TinggiInstitution of Higher Learning

Institut PenyelidikanResearch Institute

Syarikat AsingForeign Company

Agensi STISTI Agency

ii. Nama Kolaborator / Name of Collaborator

iii. Nama Orang untuk Dihubungi / Name of Contact Person

iv. Alamat Surat Menyurat / Correspondence Address

v. Nombor Telefon / Telephone Number PejabatOffice

BimbitMobile

vi. Nombor Faks/ Fax Number

vii. Emel / Email

viii. Nombor Pendaftaran Syarikat (jika berkenaan)Company Registration Number (if applicable)

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ix. Modal Dibenarkan (Bagi Syarikat)/ Authorised Capital (For Company)

x. Modal Berbayar (Bagi Syarikat)/ Paid Up Capital (For Company)

xi. Struktur Pemegang Syer/ Shareholder Structure

Kerakyatan Bil. SyerNo. of Shares %

MalaysiaMalaysian

BumiputeraBumiputera

Bukan BumiputeraNon-Bumiputera

AsingForeign

JUMLAH/ TOTAL

xii. Senarai Pemegang Syer/ List of Shareholders

Nama Pemegang SyerName of Shareholder


No. Kad Pengenalan/ No. Pasport/ No. Kad Pengenalan TenteraIdentification Card No./ Passport No./ Military Identification Card No.

Bil. SyerNo. of Shares

%Biasa/

CommonPilihan/

Preferred

xiii. Senarai Lembaga Pengarah/ List of Board of DirectorsNamaName


AlamatAddress

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xiv. Bidang Utama / Core Business

xv. Syarikat Induk (jika berkenaan)/ Parent Company (if applicable)

xvi. Alamat Syarikat Induk (jika berkenaan) / Parent Company Address (if applicable)

xvii. Senarai subsidiari atau syarikat berkaitan / List of Any Subsidiary or Related Company

xviii. Apakah produk atau servis perniagaan yang ditawarkan? /What is the Business Product or Service Offered?

1233.13.23.33.43.53.63.7

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3.83.93.103.113.123.133.143.153.163.173.183.193.20xix. Pengesahan Kolaborator/Collaborator Acknowledgement

Nama

Name

No. Kad Pengenalan Identification Card No.

Perakuan / Acknowledgement

Saya/kami mengesahkan bahawa sepanjang pengetahuan saya/kami semua maklumat kolaborator yang diberikan adalah benar dan betul

I /we hereby declare that all the collaborator information submitted is true and correct to the best of my / our knowledge

Tarikh/Date:

Tandatangan/Signature:

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L. MAKLUMAT LATAR BELAKANG ENTITI DAN KOLABORATORBACKGROUND INFORMATION OF ENTITY AND COLLABORATOR

1i. Adakah entiti, kolaborator atau mana-mana ahli kumpulannya pernah memohon atau

terlibat dengan sebarang permohonan pembiayaan dari dana Kerajaan? Jika ya, sila huraikanHas the entity, collaborator or any of its members applied or been connected with an application for any Government funding? If yes, please elaborate.

1) Nyatakan jenis dana,tajuk projek, jumlah pembiayaan dan peranan di dalam projekPlease state the type of fund, title of project, allocation amount and role in the project

2) Status projek (menunggu keputusan permohonan/dalam pelaksanaan/sempurna)Project status (awaiting result of application/in implementation/completed)

ii. Adakah entiti, kolaborator atau mana-mana ahli kumpulannya pernah disabit dengan aktiviti penyelewengan? Jika ya, sila huraikan.Has the entity, collaborator or any of its members been convicted for any fraudulent activities? If yes, please elaborate.

iii. Adakah entiti, kolaborator atau mana-mana ahli kumpulannya pernah menjadi pemilik, rakan kongsi atau pengarah bagi sebarang urus niaga yang diisytihar bankrap, dibubarkan atau di bawah kuasa penerima? Jika ya, sila huraikan.Has the entity, collaborator or any of its members ever been an owner, partner or director of a business which went into bankruptcy, liquidation or receivership? If yes, please elaborate.

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M. PERMINTAAN PASARAN /MARKET DEMAND

i. Keperluan Pasaran/ Market Need

ii. Saiz Pasaran/ Market Size

iii. Pertumbuhan Pasaran/ Market Growth

iv. Sasaran Pasaran/ Target Market

v. Persaingan Harga/ Price Competitiveness

vi. Pesaing Industri/ Industry Competitors

vii. Halangan Penglibatan/ Entry Barriers

viii. Pasaran Niche/ Niche Market

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Seksyen ini perlu ditandatangani oleh individu yang diberikan kuasa sah dari segi perundangan untuk mewakili entiti dalam pemeteraian perjanjian

This section must be signed by an individual with the legal authority to represent the entity in the signing of contract

Saya / Kami mengesahkan bahawa: I / We certify that:a. Saya / Kami telah membaca, memahami dan sedia mematuhi semua terma seperti

terkandung dokumen terkini Garis Panduan Program Flagship. I / We have read, understood and agreed to abide by the latest version of the Flagship Programme Guidelines .

b. Saya sahkan bahawa sepanjang pengetahuan saya/kami semua maklumat, perbincangan, data dan dokumen di dalam permohonan ini adalah benar dan betul; danAll information provided provided in this application, negotiation, including attachments, is true and correct to the best of my / our knowledge; and

c. Saya/kami bersetuju untuk mematuhi semua Syarat pembiayiaan yang ditetapkan dari masa ke semasa yang dikuatkuasakan serta merta apabila perjanjian saya tandatangani dan

d. Entiti / Institusi bebas dari apa-apa tindakan perundangan berkaitan projek yang dipohon di dalam atau luar negaraThe Entity / Institution is free from any litigation pertaining to the proposed project in Malaysia and overseas.

Nama Ketua ProjekProject Leader’s Name

:

JawatanDesignation :

No. Kad PengenalanIdentification Card No.

:

Nama EntitiName of Entity

:

TarikhDate

:

TandatanganSignature

:

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A. PENGAKUAN DECLARATION

Cap Rasmi EntitiEntity’s Official Stamp

:

Pemohon harus menggunakan versi terkini semua dokumen permohonan. Senarai Semak Permohonan perlu dilengkapkan secara berasingan. MOSTI berhak untuk membatalkan permohonan dan kelulusan yang dibuat berdasarkan maklumat yang tidak sahih dari pemohon

Applicants must use the latest version for all the documents in the application. The Application Checklist must be completed separately. MOSTI reserves the right to revoke application and withdraw approval based on false information submitted by applicant.

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SENARAI SEMAK PERMOHONAN PROGRAM FLAGSHIPFLAGSHIP PROGRAMME APPLICATION CHECKLISTNo. RujukanReference No.

Untuk Kegunaan Pejabat

(For Office Use)Nama EntitiName of EntityNama KolaboratorName of CollaboratorTajuk ProjekProject Title

Sila tanda (√) di ruang yang berkenaan/ Please tick (√) in the appropriate box

SET A (2 salinan dicetak/ 2 printed copies) √/X

1. Borang Permohonan Program FlagshipFlagship Programme Application Form

2. Resume Terperinci Ahli ProjekDetailed Resume of Project Team

3. Bagi entiti yang merupakan Syarikat Berdaftar

i. Salinan Memorandum dan Artikel Syarikat yang disahkan oleh SSM.Certified Copy by SSM of Memorandum and Article of Association

ii. Salinan Borang 9 (Akta Syarikat, 1965) yang disahkan oleh SSM.Certified Copy by SSM of Form 9 (Company Act, 1965)

iii. Salinan Borang 24 (Akta Syarikat, 1965) yang disahkan oleh SSM.Certified Copy by SSM of Form 24 (Company Act, 1965)

iv. Salinan Borang 49 (Akta Syarikat, 1965) yang disahkan oleh SSM.Certified Copy by SSM of Form 49 (Company Act, 1965)

4. Bagi kolaborator yang merupakan Syarikat Berdaftar (sekiranya ada)

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i. Salinan Memorandum dan Artikel Syarikat yang disahkan oleh SSM.Certified Copy by SSM of Memorandum and Article of Association

ii. Salinan Borang 9 (Akta Syarikat, 1965) yang disahkan oleh SSM.Certified Copy by SSM of Form 9 (Company Act, 1965)

iii. Salinan Borang 24 (Akta Syarikat, 1965) yang disahkan oleh SSM.Certified Copy by SSM of Form 24 (Company Act, 1965)

iv. Salinan Borang 49 (Akta Syarikat, 1965) yang disahkan oleh SSM.Certified Copy by SSM of Form 49 (Company Act, 1965)

5. Salinan penyata KWSP bagi ahli projek dalam negara dan permit kerja bagi ahli projek asing / salinan surat pelantikan (bagi ahli projek yang baru atau syarikat yang baru ditubuhkan)EPF statement for local project team members and work permit for foreign team members / appointment letter (for new team members or for newly found company)

6. Dokumen Perjanjian/ Surat Setuju Terima di antara Entiti dan KolaboratorContract Agreement/ Letter Of Acceptance between Entity and Collaborator

7. Dokumen Perjanjian/ Surat Setuju Terima di antara Entiti dan JuruperundingContract Agreement/ Letter Of Acceptance between Entity and Consultants

8. *Perjanjian Perolehan IP/ Teknologi (jika berkenaan)IP/ Technology Acquisition Agreement (if applicable)

SET B (2 salinan dicetak/ 2 printed copies)

Laporan Kewangan Diaudit Terkini (maklumat jualan tahunan, penyata keuntungan dan kerugian, kunci kira-kira, unjuran aliran tunai dan lain-lain)

- Bagi entiti atau kolaborator yang merupakan Syarikat BerdaftarLatest Audited Financial Report (annual turnover, profit and loss statement, balance sheet, cash flow etc.)

- For entity or collaborator which are Registered Companies.SET C (5 salinan/ 5 copies)

Salinan SoftCopy Borang Permohonan Program Flagship

(fail berasingan di muat turun ke dalam CD)

Softcopy of Flagship Programme Application Form

(separate files downloaded into CDs)

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