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. 4.. 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.........................): ....................................................... 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 ....... Rujukan(Reference No...... 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): ………………………………………………………………………….....

.) Lain-lain................. (Sila nyatakan) : ……………………………………………………………………………........................ 3/6 ............................. (Particulars on the reason that cause for postponement........ (Please specify) : ... (Sila nyatakan) : ……………………………………………………………………………........... Butir-butir sebab memohon penangguhan........... 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................................... (Currently studying In Form Lower 6/Upper 6 and will be sitting for STPM examination this year/ next year............ (Please specify) : .................) a) Akan menduduki peperiksaan utama (Will be sitting for a major examination) Masihberada di Tingkatan Lima dan akan mengambil peperiksaan SPM pada tahun ini... Silatandakan( X ) di mana berkenaan dan kepilkan bersama dokumen sokongan yang berkaitan..................................... (Currently studying in Form Five and will be sitting for SPM examination this year............ Others............................................................................ Please mark ( X ) where appropriate and attach all relevant supporting documents............. 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............ Others.................................................................... (Silanyatakan) : ……………………………………………………………………………..... Others.. 5............................... (Please specify) : ...............) Berada di Tingkatan Enam Bawah/Atas dan akan mengambil peperiksaan STPM pada tahun ini/ tahun hadapan......................c) Nama kem untuk latihan(Camp allocated for training): ...................

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

1.2.2.3.2. Permohonan yang mengandungi maklumat yang tidak tepat atau tidak boleh dibaca tidak akan dilayan. Jaksa Pendamai.2. Penggawa. DAN Salinan resit pembayaran yuran pengajian (TERKINI) yang telah dibayar (sekurang-kurangnya ½ daripada jumlah yuran sebenar). 3. sila pastikan Borang ini diisi dengan lengkap. Untuk meluluskan permohonan anda. Penghulu. Institusi Pengajian Tinggi Awam (IPTA) 3. 3. ATAU Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi. Lain-lain kesusahan luar biasa 3. Isi borang dengan HANYAmenggunakan huruf besar dan pen mata bola. sila hubungi:Jabatan Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5.2. 3. ditandatangani dan dilampirkan dengan dokumen yang lengkap iaitu: 3.3.4. DAN 3.1.2.2.2. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian. Sedang hamil 3. 4. 3.2. Institusi Pengajian Tinggi Swasta (IPTS) 3. 3.1. 3. anda boleh membuat rayuan kepada Majlis Latihan Khidmat Negara dengan menggunakan Borang 3 (JLKN/P/:03/Pin2/10). 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. Salinan dokumen sokongan yang berkaitan.1.1. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian. Tok Sidang. 3.Arahan untuk Borang 1 (JLKN /P/:01/Pin 2/10) 1.1.1. Surat Sokongan yang jelas menyatakan kesusahan yang dialami oleh pelatih daripada Pesuruhjaya Sumpah.2.1. Rayuan itu bolehlah dialamatkan kepada:Majlis Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5.1.1. Surat pengesahan rasmi daripada doktor.1. ATAU 3.2. 3.2. Untuk makluman lanjut. Bagi yang sedang meneruskan pengajian 3.2. 3.3.3.2. Bangunan Zetro Jalan 9/27C. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. Sekiranya permohonan pihak tuan / puan anda ditolak.2. Komandan atau Pengetua Sekolah.1.2.1. ATAU Salinan surat tawaran biasiswa. tepat dan mudah dibaca.2. Bagi yang akan menduduki peperiksaan utama 3.3. Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi.2. Bagi memastikan pemprosesan segera permohonan tuan / puan. Bangunan Zetro Jalan 9/27C. 2.3.2. sila pastikan butir-butir adalah diisi dengan betul. Surat pengesahan rasmi daripada pihak sekolah.2.2. Apa-apa keadaan yang akan menimbulkan kesusahan luar biasa 3.3. ATAU Surat pengesahan rasmi daripada Lembaga Peperiksaan Malaysia. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5/6 . Majistret.

Instructions for Form 1 (JLKN/P/:01/Pin 2/10) 1.3. Penghulu.2. If your application is rejected. OR A formal letter from the Examination Council of Malaysia 2.1 3. 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.3. accurate and legible. AND A copy of the receipt (LATEST) proving payment of fees to the current Higher Educational Institution that the applicant is attending. signed by the applicant and enclosed with all the required documents: 3. The appeal shall be addressed to :National Service Training Council Ministry of Defence Malaysia Aras 2-5.2.3.4 A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.2.2.2. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. Bangunan Zetro Jalan 9/27C. For those who are pursuing studies 3.2. please contact :National Service Training Department Ministry of Defence Malaysia Aras 2-5. For further enquiries.2 4.1 3.1 For those that will be sitting for a major examination 3. 3.1 Currently pregnant 3. 3. Tok Sidang. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 6/6 . Magistrate. Penggawa.2.2. OR A copy of the Scholarship Offer Letter proving that the course that the applicant is attending will be sponsored by a third party.2 Higher Educational Institution (Private) 3.2. Commandant or School Principal certifying that the applicant is undergoing that particular hardship. OR A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.1.3 A copy of the Letter of Offer stating the duration of the course by the current Higher Educational Institution that the applicant is attending. Bangunan Zetro Jalan 9/27C. please make sure that this form is filled upcompletely.2.2 A copy of any supporting documents proving that the applicant is undergoing that particular hardship.1.2 3.1. Kindly fill up this application form using ONLY block letters and ball point pen. To expedite this application.2. please make sure that all details filled up are correct. 3.1 A formal confirmation letter from a doctor Other exceptional hardship 3. OR 3.3.2 A formal letter from the current school.3 Any other circumstances that will give rise to exceptional hardship 3.2.2 3.2.2 A copy of the Letter of Offer stating the duration of the course by the current Higher Educational Institution that the applicant is attending.3.1 3. 3. an appeal shall lie to the National Service Training Council by using form JLKN/P/:03/PIN 2/10.2. To ensure prompt process of your application. Justice of Peace.1 A formal appeal letter certified by a Commissioner for Oath. AND 3.1 Higher Educational Institution (Public) 3. The National Service Training Department reserves the right to reject application that is incomplete.1.1.

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