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

. alamat dan nombor telefon penyokong (Name................ Nama........... Tarikh(Date) 4/6 . Tandatangan pemohon(Applicant’s signature) ...................................... 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.....

Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5/6 . Bagi yang akan menduduki peperiksaan utama 3.3.1.2.1. 3.1. DAN 3.1.1. Surat Sokongan yang jelas menyatakan kesusahan yang dialami oleh pelatih daripada Pesuruhjaya Sumpah. Surat pengesahan rasmi daripada pihak sekolah. 3. ATAU 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5.3.2.1. ATAU Salinan surat tawaran biasiswa. Bagi yang sedang meneruskan pengajian 3.1. 3. Surat pengesahan rasmi daripada doktor. Bangunan Zetro Jalan 9/27C.2. Tok Sidang.2. tepat dan mudah dibaca.1.2.2. ATAU Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi.3. Permohonan yang mengandungi maklumat yang tidak tepat atau tidak boleh dibaca tidak akan dilayan.2.2. Lain-lain kesusahan luar biasa 3. Institusi Pengajian Tinggi Awam (IPTA) 3. Majistret. Bangunan Zetro Jalan 9/27C. sila hubungi:Jabatan Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5. 3.2. ATAU Surat pengesahan rasmi daripada Lembaga Peperiksaan Malaysia. Institusi Pengajian Tinggi Swasta (IPTS) 3.2.1.3. Bagi memastikan pemprosesan segera permohonan tuan / puan. 3.1. Sedang hamil 3. 3.3.Arahan untuk Borang 1 (JLKN /P/:01/Pin 2/10) 1. sila pastikan Borang ini diisi dengan lengkap.1. Untuk makluman lanjut. Salinan dokumen sokongan yang berkaitan. 3.2. Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi.4. Apa-apa keadaan yang akan menimbulkan kesusahan luar biasa 3.2.2. DAN Salinan resit pembayaran yuran pengajian (TERKINI) yang telah dibayar (sekurang-kurangnya ½ daripada jumlah yuran sebenar). ditandatangani dan dilampirkan dengan dokumen yang lengkap iaitu: 3. Penghulu. 4. anda boleh membuat rayuan kepada Majlis Latihan Khidmat Negara dengan menggunakan Borang 3 (JLKN/P/:03/Pin2/10).2. Untuk meluluskan permohonan anda. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian.3.1. Jaksa Pendamai.2. 3. Komandan atau Pengetua Sekolah. Sekiranya permohonan pihak tuan / puan anda ditolak.2.2.1. Rayuan itu bolehlah dialamatkan kepada:Majlis Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5. 2. Isi borang dengan HANYAmenggunakan huruf besar dan pen mata bola.2.2. sila pastikan butir-butir adalah diisi dengan betul.2. 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. Penggawa. 3.2.3.

2.4 A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution. Penghulu. Commandant or School Principal certifying that the applicant is undergoing that particular hardship.1 3.2. please contact :National Service Training Department Ministry of Defence Malaysia Aras 2-5.2. Bangunan Zetro Jalan 9/27C. 3. Magistrate.Instructions for Form 1 (JLKN/P/:01/Pin 2/10) 1. 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. signed by the applicant and enclosed with all the required documents: 3.2 3.1 A formal confirmation letter from a doctor Other exceptional hardship 3.2. To expedite this application. If your application is rejected. Kindly fill up this application form using ONLY block letters and ball point pen. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5.2.3. AND A copy of the receipt (LATEST) proving payment of fees to the current Higher Educational Institution that the applicant is attending. Justice of Peace.3.2 3.1.2.2 A formal letter from the current school.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. OR A formal letter from the Examination Council of Malaysia 2. To ensure prompt process of your application. OR 3.1 3.2. Penggawa.1 A formal appeal letter certified by a Commissioner for Oath. Tok Sidang. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 6/6 . Bangunan Zetro Jalan 9/27C. please make sure that all details filled up are correct. For further enquiries. The National Service Training Department reserves the right to reject application that is incomplete. 3.2.3.2 A copy of any supporting documents proving that the applicant is undergoing that particular hardship.1.2.1.2 4.2. please make sure that this form is filled upcompletely. OR A copy of the Scholarship Offer Letter proving that the course that the applicant is attending will be sponsored by a third party. 3.2.2 Higher Educational Institution (Private) 3. AND 3. an appeal shall lie to the National Service Training Council by using form JLKN/P/:03/PIN 2/10. accurate and legible.1 Currently pregnant 3.1 Higher Educational Institution (Public) 3. For those who are pursuing studies 3.3 Any other circumstances that will give rise to exceptional hardship 3.3 A copy of the Letter of Offer stating the duration of the course by the current Higher Educational Institution that the applicant is attending. 3. The appeal shall be addressed to :National Service Training Council Ministry of Defence Malaysia Aras 2-5.2.2.1.1 For those that will be sitting for a major examination 3.3.1 3. OR A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.1.3.2.

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