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

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

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

DAN Salinan resit pembayaran yuran pengajian (TERKINI) yang telah dibayar (sekurang-kurangnya ½ daripada jumlah yuran sebenar).2.2. tepat dan mudah dibaca.1. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian. Tok Sidang. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian. 4.1.3.2.2.1. Apa-apa keadaan yang akan menimbulkan kesusahan luar biasa 3. 2. 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. ditandatangani dan dilampirkan dengan dokumen yang lengkap iaitu: 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5/6 .1. sila pastikan Borang ini diisi dengan lengkap. Sedang hamil 3. Komandan atau Pengetua Sekolah. ATAU 3. Institusi Pengajian Tinggi Awam (IPTA) 3.2.2. DAN 3.2.2.2. Jaksa Pendamai. Salinan dokumen sokongan yang berkaitan. Penggawa. sila pastikan butir-butir adalah diisi dengan betul.1. 3. 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. Majistret.2. Isi borang dengan HANYAmenggunakan huruf besar dan pen mata bola.2. Bangunan Zetro Jalan 9/27C. 3.2.3. Surat pengesahan rasmi daripada pihak sekolah.1. sila hubungi:Jabatan Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5. Untuk meluluskan permohonan anda.3. Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi.3. 3.3. 3.1.3.3. anda boleh membuat rayuan kepada Majlis Latihan Khidmat Negara dengan menggunakan Borang 3 (JLKN/P/:03/Pin2/10).2. Untuk makluman lanjut.1. 3.2. Sekiranya permohonan pihak tuan / puan anda ditolak.2.2.Arahan untuk Borang 1 (JLKN /P/:01/Pin 2/10) 1. Rayuan itu bolehlah dialamatkan kepada:Majlis Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5.2. Surat Sokongan yang jelas menyatakan kesusahan yang dialami oleh pelatih daripada Pesuruhjaya Sumpah. Bagi memastikan pemprosesan segera permohonan tuan / puan. ATAU Surat pengesahan rasmi daripada Lembaga Peperiksaan Malaysia.1. 3. Penghulu. Bagi yang akan menduduki peperiksaan utama 3. Bagi yang sedang meneruskan pengajian 3. Permohonan yang mengandungi maklumat yang tidak tepat atau tidak boleh dibaca tidak akan dilayan. Surat pengesahan rasmi daripada doktor. 3.1. Bangunan Zetro Jalan 9/27C. Institusi Pengajian Tinggi Swasta (IPTS) 3.4. 3.1.2.2.1.1. ATAU Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi.2.2. Lain-lain kesusahan luar biasa 3. ATAU Salinan surat tawaran biasiswa.

2 3.2.3. please make sure that this form is filled upcompletely. To expedite this application. Justice of Peace.1.2.2.2.2. OR 3.2 4.2 3. Penghulu.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.2.1. To ensure prompt process of your application. The appeal shall be addressed to :National Service Training Council Ministry of Defence Malaysia Aras 2-5.2.3 Any other circumstances that will give rise to exceptional hardship 3.1 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. 3.2.2. If your application is rejected. Penggawa. Tok Sidang. please make sure that all details filled up are correct. For further enquiries.4 A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution. accurate and legible.2.2.1. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 6/6 . AND A copy of the receipt (LATEST) proving payment of fees to the current Higher Educational Institution that the applicant is attending. For those who are pursuing studies 3. please contact :National Service Training Department Ministry of Defence Malaysia Aras 2-5.1 Currently pregnant 3.1 3.3.2. Bangunan Zetro Jalan 9/27C.3. The National Service Training Department reserves the right to reject application that is incomplete. OR A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution. Kindly fill up this application form using ONLY block letters and ball point pen. 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.2 A copy of any supporting documents proving that the applicant is undergoing that particular hardship. 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. 3. signed by the applicant and enclosed with all the required documents: 3.Instructions for Form 1 (JLKN/P/:01/Pin 2/10) 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. Magistrate. AND 3.1 A formal appeal letter certified by a Commissioner for Oath.3.1 Higher Educational Institution (Public) 3.2 A formal letter from the current school.2 Higher Educational Institution (Private) 3. OR A formal letter from the Examination Council of Malaysia 2.1 3.1.2.1 For those that will be sitting for a major examination 3. Bangunan Zetro Jalan 9/27C.1 A formal confirmation letter from a doctor Other exceptional hardship 3.1. Commandant or School Principal certifying that the applicant is undergoing that particular hardship. 3. an appeal shall lie to the National Service Training Council by using form JLKN/P/:03/PIN 2/10.