Borang 1 (Form 1) JLKN /P/:01/Pin 2/10

AKTA LATIHAN KHIDMAT NEGARA 2003 (NATIONAL SERVICE TRAINING ACT 2003) PERATURAN-PERATURAN LATIHAN KHIDMAT NEGARA (PENANGGUHAN TANGGUNGAN) 2004 (NATIONAL SERVICE TRAINING (POSTPONEMENT OF LIABILITY) REGULATIONS 2004) PERMOHONAN BAGIPERAKUAN PENANGGUHAN (Peraturan 3) (APPLICATION FOR POSTPONEMENT OF LIABILITY/ POSTPONEMENT CERTIFICATE) (Regulation 3) *(Sila baca arahan di muka surat 5 dan 6sebelum mengisi borang ini) (Please read the instructions on page 5 and 6before filling up this form)

1. Nama(Name):

2. No kad pengenalan(NRIC number):

Kegunaan rasmi (Official use)— Diterima oleh (Received by) :.......................................................................................................

Tarikh diterima(Date received) :....................................................................................................... Siri (Series) Kumpulan (Group) :............../.................... :1 2 3

Kod (Code)

:1

2

3

Keputusan(Decision)

: Lulus (Approved) / Tidak Lulus (Not Approved)

.............................................. Ketua Pengarah (Director General) /bagi pihak Ketua Pengarah (on behalf of Director General)

............................. Tarikh (Date)

1/6

.............................3................................ Tarikh(Date): Hari (Date) Bulan (Month) Tahun (Year) b) Tarikh melapor diri untuk latihan: (Date to report for training) Tarikh(Date): Hari (Date) Bulan (Month) Tahun (Year) 2/6 .... Butir-butir tentang Program Latihan Khidmat Negara (Particulars relating to National Service Training) a) Nombor rujukan dan tarikh surat pemberitahuan(Reference number and date of notification letter): No............. 4...... Butir-butir peribadi(Personal Particulars) a) Alamat tetap(Permanent address): Poskod(Postcode): Negeri(State): Bandar (City): b) Alamatsurat-menyurat [Jika berbeza daripada di atas] (Postal address [If different from above]): Poskod(Postcode): Negeri(State): Bandar (City): c) Nombor telefon(Telephone numbers): Rumah (House): Bimbit (Handphone): Lain-lain (Others): d) Alamat e-mel(E-mail address): …………………………………………………………………………..............): ....... Rujukan(Reference No..

. (Sila nyatakan) : ……………………………………………………………………………........................................................................................................ Others............ 3/6 .. c) Keadaan yang akan menimbulkan kesusahan luar biasa(Circumstances that will give rise to exceptional hardships) Sedang hamil (Currently pregnant) Tarikh dijangka bersalin (Expected date of giving birth) : Hari : (Date) Bulan (Month) Tahun (Year) Lain-lain..................................... (Currently studying In Form Lower 6/Upper 6 and will be sitting for STPM examination this year/ next year............................. Silatandakan( X ) di mana berkenaan dan kepilkan bersama dokumen sokongan yang berkaitan...........) Berada di Tingkatan Enam Bawah/Atas dan akan mengambil peperiksaan STPM pada tahun ini/ tahun hadapan... Others...... (Please specify) : ....................c) Nama kem untuk latihan(Camp allocated for training): ............) Lain-lain. (Currently studying in Form Five and will be sitting for SPM examination this year.............) a) Akan menduduki peperiksaan utama (Will be sitting for a major examination) Masihberada di Tingkatan Lima dan akan mengambil peperiksaan SPM pada tahun ini................. 5...... Please mark ( X ) where appropriate and attach all relevant supporting documents........................................ Butir-butir sebab memohon penangguhan....................... (Particulars on the reason that cause for postponement....... (Silanyatakan) : ……………………………………………………………………………....................... Others........ b) Sedang meneruskan pengajian (Currently pursuing studies) Sedang meneruskan pengajian di mana-mana institusi pengajian tinggi (Pursuing studies inany higher educational institutions) Tarikh mula belajar (Date of commence) Tarikh dijangka tamat belajar (Expected date of completion) : Hari : (Date) : Hari : (Date) Bulan (Month) Bulan (Month) Tahun (Year) Tahun (Year) Lain-lain............ (Please specify) : ........... (Please specify) : ..................... (Sila nyatakan) : ……………………………………………………………………………................................................................

... Senarai dokumen sokongan (List of supporting documents) a) b) c) d) ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… 7. address and telephone numbers of referees) Nama (Name) a) Alamat (Address) Rumah (House) Bimbit (Handphone) b) .................6........................................ alamat dan nombor telefon penyokong (Name. Tandatangan pemohon(Applicant’s signature) ..................... Nama......... Tarikh(Date) 4/6 ................

2. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. 3. sila hubungi:Jabatan Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5. Surat pengesahan rasmi daripada doktor. Bangunan Zetro Jalan 9/27C.2. Surat pengesahan rasmi daripada pihak sekolah. Rayuan itu bolehlah dialamatkan kepada:Majlis Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5. ATAU Salinan surat tawaran biasiswa.1.1. 4. Sedang hamil 3. DAN Salinan resit pembayaran yuran pengajian (TERKINI) yang telah dibayar (sekurang-kurangnya ½ daripada jumlah yuran sebenar).2.2.1.2. Penggawa. ATAU Surat pengesahan rasmi daripada Lembaga Peperiksaan Malaysia. sila pastikan Borang ini diisi dengan lengkap. 2.Arahan untuk Borang 1 (JLKN /P/:01/Pin 2/10) 1. Tok Sidang. tepat dan mudah dibaca. Bagi yang sedang meneruskan pengajian 3. anda boleh membuat rayuan kepada Majlis Latihan Khidmat Negara dengan menggunakan Borang 3 (JLKN/P/:03/Pin2/10).3. Isi borang dengan HANYAmenggunakan huruf besar dan pen mata bola. Salinan dokumen sokongan yang berkaitan.2. Bagi memastikan pemprosesan segera permohonan tuan / puan. Apa-apa keadaan yang akan menimbulkan kesusahan luar biasa 3. 3.1.2. 3. ditandatangani dan dilampirkan dengan dokumen yang lengkap iaitu: 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5/6 .2.2. Bagi yang akan menduduki peperiksaan utama 3.1.3.1.1. sila pastikan butir-butir adalah diisi dengan betul. Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi. 3. Penghulu. Untuk makluman lanjut.1.1. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian.2.1. Bangunan Zetro Jalan 9/27C. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian. Untuk meluluskan permohonan anda. Institusi Pengajian Tinggi Swasta (IPTS) 3. ATAU 3. 3. 3.2. Komandan atau Pengetua Sekolah.2. 3.4.3. 3. Jaksa Pendamai.2.1.3. Sekiranya permohonan pihak tuan / puan anda ditolak.1.2.1. Institusi Pengajian Tinggi Awam (IPTA) 3.2. Lain-lain kesusahan luar biasa 3.2.2. DAN 3. Majistret.3. ATAU Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi. Semua permohonan bagi perakuan penangguhan hendaklah dibuat dalam masa sepuluh (10) hari selepas penyiaran perintah Menteri yang menghendaki peserta menjalani Latihan Khidmat Negara atau dalam tempoh masa yang dipanjangkan sebagaimana yang boleh dibenarkan oleh pihak berkuasa yang sepatutnya.3.2.2. 3.2.3.2. Permohonan yang mengandungi maklumat yang tidak tepat atau tidak boleh dibaca tidak akan dilayan. Surat Sokongan yang jelas menyatakan kesusahan yang dialami oleh pelatih daripada Pesuruhjaya Sumpah.

Instructions for Form 1 (JLKN/P/:01/Pin 2/10) 1. For those who are pursuing studies 3.2 3.2.1.3.1.2.2.2 4. please contact :National Service Training Department Ministry of Defence Malaysia Aras 2-5.1 3. The National Service Training Department reserves the right to reject application that is incomplete.2.4 A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.1 Higher Educational Institution (Public) 3.2.1 A formal appeal letter certified by a Commissioner for Oath.2.2.2.2.1. The appeal shall be addressed to :National Service Training Council Ministry of Defence Malaysia Aras 2-5.3 Any other circumstances that will give rise to exceptional hardship 3. Magistrate. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 6/6 . Penggawa.2. AND A copy of the receipt (LATEST) proving payment of fees to the current Higher Educational Institution that the applicant is attending. For further enquiries. 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. 3.2.2 3. OR A copy of the Scholarship Offer Letter proving that the course that the applicant is attending will be sponsored by a third party.1. an appeal shall lie to the National Service Training Council by using form JLKN/P/:03/PIN 2/10. Kindly fill up this application form using ONLY block letters and ball point pen.3.3. 3. OR A formal letter from the Examination Council of Malaysia 2.1 A formal confirmation letter from a doctor Other exceptional hardship 3. signed by the applicant and enclosed with all the required documents: 3.2 A copy of the Letter of Offer stating the duration of the course by the current Higher Educational Institution that the applicant is attending. All applications for a postponement certificate must be made within ten (10) days after the publication of the order of the Minister requiring participants to undergo national service training or within such extended time as the proper authority may allow. To ensure prompt process of your application.2.2 A copy of any supporting documents proving that the applicant is undergoing that particular hardship.2 A formal letter from the current school. 3.2 Higher Educational Institution (Private) 3. AND 3. If your application is rejected.3.1. Bangunan Zetro Jalan 9/27C. Bangunan Zetro Jalan 9/27C. Commandant or School Principal certifying that the applicant is undergoing that particular hardship.3. accurate and legible.3 A copy of the Letter of Offer stating the duration of the course by the current Higher Educational Institution that the applicant is attending. please make sure that all details filled up are correct. Penghulu. OR 3. OR A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution. Justice of Peace.1 3.1 3.1 Currently pregnant 3. To expedite this application. Tok Sidang.2.1 For those that will be sitting for a major examination 3.2. please make sure that this form is filled upcompletely.

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