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) :....................................................................................................... Siri (Series) Kumpulan (Group) :............../.................... :1 2 3

Kod (Code) Keputusan (Decision)

:1

2

3

: Lulus (Approved) / Tidak Lulus (Not Approved)

.............................................. Ketua Pengarah (Director General) /bagi pihak Ketua Pengarah (on behalf of Director General)

............................. Tarikh (Date)

1/6

................3.......................... Rujukan (Reference No. 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........ Butir-butir peribadi (Personal Particulars) a) Alamat tetap (Permanent address): Poskod (Postcode): Negeri (State): Bandar (City): b) Alamat surat-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 .........................................): ....

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

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

2.1.2.1. Surat pengesahan rasmi daripada doktor.2.3. Tok Sidang.Arahan untuk Borang 1 (JLKN /P/:01/Pin 2/10) 1.1. Apa-apa keadaan yang akan menimbulkan kesusahan luar biasa 3. 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5/6 . Penggawa. 3. 6. Isi borang dengan HANYA menggunakan huruf besar dan pen mata bola. 4. Penghulu.1. 3.3. Jaksa Pendamai. 3. Bangunan Zetro Jalan 9/27C. ATAU Salinan surat tawaran biasiswa dan disahkan salinan sebenar. Sekiranya permohonan pihak tuan / puan anda ditolak.2. DAN Salinan resit pembayaran yuran pengajian (TERKINI) yang telah dibayar (sekurang-kurangnya ½ daripada jumlah yuran sebenar) dan disahkan salinan sebenar.2. sila pastikan Borang ini diisi dengan lengkap. Bagi memastikan pemprosesan segera permohonan tuan / puan. Bagi yang sedang meneruskan pengajian 3.1. Bagi yang akan menduduki peperiksaan utama 3. 3.2.2. Lain-lain kesusahan luar biasa 3.2. 2. Komandan atau Pengetua Sekolah. Untuk makluman lanjut. Penghulu.2.2. 3.2. Komandan atau Pengetua Sekolah. Rayuan itu bolehlah dialamatkan kepada:Majlis Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5.3.2.2. 3. ditandatangani dan dilampirkan dengan dokumen yang lengkap iaitu: 3. Surat Sokongan yang jelas menyatakan kesusahan yang dialami oleh pelatih daripada Pesuruhjaya Sumpah.1. 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. ATAU 3. sila pastikan butir-butir adalah diisi dengan betul.2. Permohonan yang mengandungi maklumat yang tidak tepat atau tidak boleh dibaca tidak akan dilayan.4. Salinan dokumen sokongan yang dikemukakan kepada Jabatan Latihan Khidmat Negara hendaklah disahkan salinan sebenar oleh Pesuruhjaya Sumpah. anda boleh membuat rayuan kepada Majlis Latihan Khidmat Negara dengan menggunakan Borang 3 (JLKN/P/:03/Pin2/10).2. tepat dan mudah dibaca. Institusi Pengajian Tinggi Swasta (IPTS) 3.1.1.1.3. Majistret. sila hubungi:Jabatan Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5.2.2.3. Penggawa. ATAU Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi.2.2. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian dan disahkan salinan sebenar.2. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian dan disahkan salinan sebenar. DAN 3. Institusi Pengajian Tinggi Awam (IPTA) 3. Majistret.1.3. Surat pengesahan rasmi daripada pihak sekolah.2. Sedang hamil 3. Untuk meluluskan permohonan anda. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi. Salinan dokumen sokongan yang telah disahkan salinan sebenar. Jaksa Pendamai.1. Tok Sidang. ATAU Surat pengesahan rasmi daripada Lembaga Peperiksaan Malaysia.1.3.1. Bangunan Zetro Jalan 9/27C. 3.

Magistrate. Commandant or School Principal.1 A formal appeal letter certified by a Commissioner for Oath.2 Higher Educational Institution (Private) 3. signed by the applicant and enclosed with all the required documents: 3. OR 3. Bangunan Zetro Jalan 9/27C. The appeal shall be addressed to :National Service Training Council Ministry of Defence Malaysia Aras 2-5.1 For those that will be sitting for a major examination 3.1. 3. 3. Bangunan Zetro Jalan 9/27C. Penggawa. please make sure that this form is filled up completely. accurate and legible.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.3.2. AND A certified copy of the receipt (LATEST) proving payment of fees to the current Higher Educational Institution that the applicant is attending. 6/6 .2.1. To ensure prompt process of your application.2 4. 3. Magistrate. The National Service Training Department reserves the right to reject application that is incomplete.3 Any other circumstances that will give rise to exceptional hardship 3. 6.1.4 A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.2.2 3.2.2. Justice of Peace. To expedite this application.2.2 A formal letter from the current school. OR A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution. Penggawa. All documents submitted to the National Service Training Department must be certified true copies by a Commissioner for Oath.2.1 Currently pregnant 3.1 3. 3.Instructions for Form 1 (JLKN/P/:01/Pin 2/10) 1.3.2. OR A certified copy of the Scholarship Offer Letter proving that the course that the applicant is attending will be sponsored by a third party.1 A formal confirmation letter from a doctor Other exceptional hardship 3.2 A certified copy of the Letter of Offer stating the duration of the course by the current Higher Educational Institution that the applicant is attending.1 Higher Educational Institution (Public) 3. Kindly fill up this application form using ONLY block letters and ball point pen.2.2. Tok Sidang.2. Penghulu.1 3. OR A formal letter from the Examination Council of Malaysia 2.1 3. an appeal shall lie to the National Service Training Council by using form JLKN/P/:03/PIN 2/10. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. Commandant or School Principal certifying that the applicant is undergoing that particular hardship. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur For further enquiries.2. For those who are pursuing studies 3.1. please contact :National Service Training Department Ministry of Defence Malaysia Aras 2-5. Tok Sidang.3. Penghulu. please make sure that all details filled up are correct.3.2.3 A certified copy of the Letter of Offer stating the duration of the course by the current Higher Educational Institution that the applicant is attending.2 3.2 A certified copy of any supporting documents proving that the applicant is undergoing that particular hardship. Justice of Peace. AND 3.1.2. If your application is rejected.