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 BAGI PERAKUAN PENANGGUHAN (Peraturan 3) (APPLICATION FOR POSTPONEMENT OF LIABILITY/ POSTPONEMENT CERTIFICATE) (Regulation 3) * (Sila baca arahan di muka surat 5 dan 6 sebelum mengisi borang ini) (Please read the instructions on page 5 and 6 before 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) Sir (Series) : J Kumpulan (Group) a{_] 3[_] Kod (Code) fl 2 3 Keputusan (Decision) : Lulus (Approved) Tidak Lulus (Not Approved) Ketva Pengarah (Director General) “"Tarikh (Date) Ihagi pihak Ketua Pengarah (on behalf of Director General) v63 4 Butir-butir peribadi (Personal Particulars) a) b) a) Alamat tetap (Permanent address) Poskad (Postcode): Bandar (City): Negeri (State): Alamat surat-menyurat [Jika berbeza daripa da di atas] (Postal address [if different from above) Poskod (Postcode): Bandar (City) Negeri (State): Nombor telefon (Telephone numbers): Rumah (House) Bimbit (Handphone): Lain-lain (Others) 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,): . Tarikh (Date): Hari Bulan Tahun (Cate)| (Month) (Year) Tarikh melapor diri untuk latihan: (Date fo report for training) Tarikh (Date): Hari Bulan Tahun (Date)| (Month) (Year) 216) Nama kem untuk latihan (Camp allocated for training): Butir-butir sebab memohon penangguhan, Sila tandakan (X) dimana berkenaan dan kepitkan bersama dokumen sokongan yang berkaitan. (Particulars on the reason that cause for postponement. Please mark (X) where appropriate and attach all relevant supporting documents.) a) Akan menduduki peperiksaan utama (Will be sitting for a major examination) Masih berada di Tingkatan Lima dan akan mengambil peperiksaan SPM pada tahun ini (Currently studying in Form five and will be sitting for SPM examination this year.) Berada di Tingkatan Enam Bawah/Atas dan akan mengambil peperiksaan STPM pada tahun inif tahun hadapan, (Currently studying In Form lower 6/Upper 6 and will be sitting for STPM examination this year/ next year.) Lain-tain. (Sila nyatakan) Others. (Please specify) : b) Sedang meneruskan pengajian (Currently pursuing studies) ‘Sedang meneruskan pengajian di mana-mana institusi pengajian tinggi (Pursuing studies in any higher educational institutions) Tarikh mula belajar Hari Bulan Tahun (Date of commence) (Date)| (Month) (Year) Tarikh dijangka tamat belajar _—: Hari Bulan Tahun (Expected date of completion): (Date) (Month) (Year) Lain-tain. (Sila nyatakan) Others. (Please specify) x ‘eadaan yang akan menimbulkan kesusahan luar biasa (Circumstances that will give rise to exceptional hardships) ‘Sedang hamil (Currently pregnant) Tarikh dijangka bersalin Hari Bulan Tahun (Expected date of giving birth): (Date) (Month) (Year) Lain-tain. (Sila nyatakan) Others. (Please specify) 366. _Senarai dokumen sokongan (List of supporting documents) a) b) °) d) 7. Nama, alamat dan nombor telefon penyokong (Name, address and telephone numbers of referees) ‘Nama (Name) ‘Alamat (Address) ‘Rumah (House) ‘Bimbit (Handphone) 2) >) ‘Tandatangan pemohon (Applicant's signature) ‘Tarikh (Date) 416a an untuk Borang 1 (2UKN IPLOWPIn 2710) Is brang dengan HANYA menggunakan hurt besar dan pon mata boa. Bagi memastkan pemprosesansogera permshonantuan!puan, la pastuan bue-bitr alah si dengan Bet, opal dan mdan bac, Permahonan yang mengandurg maka yang tak op at ‘Semua psrmohoran bagi perakuan perangguhan hendalah sibuat dalam masa sepuuh (10) hai selopas ponyiaranparntah Mentor yang len phak beraasa yang sepatunys, 3 don dllampirkan dengan dokumen Untuk meluluskan pe-mohonan anda, sla pastkan Bora in lst dengan longkap,tandatange 3.4 Baglyang akan mendud peperkssan uta, 312 Siratpengeeshan reenl darpada Lembage Pape 7 Malaysia 3.2 Bagi yang sedang meneruskan pengaian 324 nets! Pangan Tigo! Awa (TA) 3212. Suratrasmi mengesshkan behawa pamchon sodeng manghad kursus (sla nyatkan tempoh pengoan) arpa ists pongalan ng 322 Instus|Pengalan Tngg Swasta (PTS) 322.1 Salnan surat tavaranbebjardaripada nits] pengaantngal yan cnylakantempch peogafan, DAN 3222. Satnan rest pemyaran yuren pengajan (TERKIN!) yang teh eayar sekuvangurangnya 12 a kiahyuranseborar, ATAU 9223 Salman srt tuaran Sasioes, vada iatius pengajan tng. 33 Apa-apa keadaan yang akan menimbulkan kesusahan var basa aa Sedang ham 33.1.1 Suratpongesshan esmi darpada dota 332.1 Surat Sokongan yang jlas meryslakan kesusshan yang lslaml oleh pelah danpada Pesurumaya Sump, Majsot, Penghul, Ponggawa, Tok Sarg, Jaksa Pendams, Komangar atau Pangota Selah. AN 3822 Salman dokumen soxongon, ‘Seirnya permohonan pak an / pun anda dol, anda both membuatrayuan kepada Mails Laan Knidmat Negara dengan mmenggunatan Barang 3 JLKNIP:03/PIn2"0), Reyuan fu boll dlarathan kopada Kemenvaian Pertahanan Malaysia ‘ras 25, Bangunan Zot ‘alan 9370. Seksyon 8 53900 Kuala Lumpur nuk makluman lng sa hubong abatan Lathan Kamat Negara iementenan Perahanan Malaysia eas 2-5, Bangunan Zo data 270, Sekayen 8 Wargae Maju 159000 Kuala Lumoor 561 6. Instructions for For 1 (JLKNIPF-0%7Pin 210) Kody fi up is appistion frm using ONLY bloc eters and ball point pen. To ensure prompt procas of your applcaton, please make sure that al etal filed up are corset, accrato and logble. The Naboral Serace Trahing Deparment rasorves the rah to reject All applications fora postponement cortate must be made wihin tn (10) days ater tho publeaton ofthe erdar of th Minister requting partspants to undorgs national sori ang or win such extondod tims as the proper autorty may allow. To expedte ths apleatin, passe make sure tha is fam ied up comp required document 1y, signed bythe applicant and enclosed with all the 2.14 formal eter fom the erent acnel, OR 312 Afomal ter fom the Examinaton Counc of Malye 32. For those who are pursuing stu 8.24 Higher Educational Inston (Public) 221.4. copy ofthe Letar of Ofer stating the dation ofthe course by the cuent Higher Eaucatonal Inston thatthe applicant atoning, OR 32.42 Atomal tar crying that the apaeat atendng the course (sat the course ration by be cient igh Eduestionelnstiun. 83.22 Higher Educational stun (Private) 3221 Acopy ofthe Leta of of stating the duration fhe course bythe cuent Hgher Educabona Instuten tat the applicants attending, AND 3222. Aeapy ofthe recat (LATEST) proving payment of fe othe current Higher Edueaonal ination ha {he aplcant attending, OR 3223 copy ofthe sehearship Ofer Leta proving that te course tha he apolcant atoning wilbe sponsored by a rd party 3224 A formal ltr cortyng that he applicant Is attorcing tho cours (tte the course duration) by the curent 33 Any other circumstances that wil gve rise to exceptional hardship S31 'Atomalcontematon leer tom a doctor 332 Other excoptonal hardship 3327 A omal appea air ceifed by a Commasons for Oak, Magatate, Penghul, Penggaws, Tok Sideng, sustiee of Peace, Gamandant or Shoo! Principal crying ha he appcat is undergo tel parouse harden, AND 33.22 Nested copy of any supporing docurans proving tha he applicants undergoing thal prea harden. your appcalon i rejected, an appeal sali othe Nalenal Sonica Training Coun by ung form JLKNIPLORIPn210. The appeal National Service Training Cour 13525, Bangunan Zee dak 370, Sekayon 8 Wangsa Maju Ferturnr enquires, please contact National Service Tiinng Department Minty of Defence Malaysia ras 25, Bangunan Zero Wangs Maju 15200 Koala Lumpur 616