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

. Rujukan(Reference No..........3.. 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 ............................................................): ............. 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..........

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

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

Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5/6 .2. Untuk makluman lanjut.1.2.2.1.1. Lain-lain kesusahan luar biasa 3. Surat pengesahan rasmi daripada pihak sekolah. 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. Bagi yang sedang meneruskan pengajian 3.1.2. Isi borang dengan HANYAmenggunakan huruf besar dan pen mata bola. Surat pengesahan rasmi daripada doktor. Bangunan Zetro Jalan 9/27C. Institusi Pengajian Tinggi Swasta (IPTS) 3. 3. sila hubungi:Jabatan Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5.1. 3.2.1. Rayuan itu bolehlah dialamatkan kepada:Majlis Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5.2. 3. ATAU Surat pengesahan rasmi daripada Lembaga Peperiksaan Malaysia.3.3. Jaksa Pendamai. tepat dan mudah dibaca.2.2. Tok Sidang. Apa-apa keadaan yang akan menimbulkan kesusahan luar biasa 3. 2. DAN 3. Bagi yang akan menduduki peperiksaan utama 3. anda boleh membuat rayuan kepada Majlis Latihan Khidmat Negara dengan menggunakan Borang 3 (JLKN/P/:03/Pin2/10).2.2.1.2.2.2.Arahan untuk Borang 1 (JLKN /P/:01/Pin 2/10) 1. Untuk meluluskan permohonan anda. Surat Sokongan yang jelas menyatakan kesusahan yang dialami oleh pelatih daripada Pesuruhjaya Sumpah.2.2. Majistret. sila pastikan Borang ini diisi dengan lengkap.1. Penghulu.3. 3. Penggawa. ATAU 3. Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi. 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5.2.2.1.1. 4.1.1. sila pastikan butir-butir adalah diisi dengan betul. Bagi memastikan pemprosesan segera permohonan tuan / puan.4. Bangunan Zetro Jalan 9/27C. ATAU Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian.2. ATAU Salinan surat tawaran biasiswa. 3. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian.2. Komandan atau Pengetua Sekolah. ditandatangani dan dilampirkan dengan dokumen yang lengkap iaitu: 3.3.1. DAN Salinan resit pembayaran yuran pengajian (TERKINI) yang telah dibayar (sekurang-kurangnya ½ daripada jumlah yuran sebenar).2. Institusi Pengajian Tinggi Awam (IPTA) 3. 3. Permohonan yang mengandungi maklumat yang tidak tepat atau tidak boleh dibaca tidak akan dilayan. Sekiranya permohonan pihak tuan / puan anda ditolak. Salinan dokumen sokongan yang berkaitan.3. Sedang hamil 3.2. 3.3. 3.

3.1 A formal confirmation letter from a doctor Other exceptional hardship 3.1 A formal appeal letter certified by a Commissioner for Oath.2.2.2 4.1 For those that will be sitting for a major examination 3.3.2 Higher Educational Institution (Private) 3.1. Justice of Peace. 3. For those who are pursuing studies 3.1 3. Penghulu.Instructions for Form 1 (JLKN/P/:01/Pin 2/10) 1.2. OR A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution. Magistrate. AND 3. Tok Sidang.2.2. accurate and legible. The National Service Training Department reserves the right to reject application that is incomplete.1 Higher Educational Institution (Public) 3.2. To ensure prompt process of your application.1.3. Penggawa. OR 3.1.1.3.3 A copy of the Letter of Offer stating the duration of the course by the current Higher Educational Institution that the applicant is attending. The appeal shall be addressed to :National Service Training Council Ministry of Defence Malaysia Aras 2-5.1.2 3. signed by the applicant and enclosed with all the required documents: 3. 3.2.4 A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.3 Any other circumstances that will give rise to exceptional hardship 3.1 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. 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.3.2. 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. Commandant or School Principal certifying that the applicant is undergoing that particular hardship.1 Currently pregnant 3.2.1 3. 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 6/6 .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.2 A formal letter from the current school. If your application is rejected.2. OR A formal letter from the Examination Council of Malaysia 2. To expedite this application. please contact :National Service Training Department Ministry of Defence Malaysia Aras 2-5.2. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. Bangunan Zetro Jalan 9/27C. please make sure that this form is filled upcompletely. an appeal shall lie to the National Service Training Council by using form JLKN/P/:03/PIN 2/10.2 3. Bangunan Zetro Jalan 9/27C.2 A copy of any supporting documents proving that the applicant is undergoing that particular hardship. please make sure that all details filled up are correct.

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