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

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

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

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

2.2. Apa-apa keadaan yang akan menimbulkan kesusahan luar biasa 3. 3. 3.1. Jaksa Pendamai. sila pastikan Borang ini diisi dengan lengkap.3. 4. Salinan dokumen sokongan yang dikemukakan kepada Jabatan Latihan Khidmat Negara hendaklah disahkan salinan sebenar oleh Pesuruhjaya Sumpah. Tok Sidang.3. Surat pengesahan rasmi daripada doktor.3. Sekiranya permohonan pihak tuan / puan anda ditolak. Permohonan yang mengandungi maklumat yang tidak tepat atau tidak boleh dibaca tidak akan dilayan. Rayuan itu bolehlah dialamatkan kepada:Majlis Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5.1. DAN Salinan resit pembayaran yuran pengajian (TERKINI) yang telah dibayar (sekurang-kurangnya ½ daripada jumlah yuran sebenar) dan disahkan salinan sebenar. Untuk makluman lanjut.3.4. 3. 3.2. Lain-lain kesusahan luar biasa 3. Sedang hamil 3.1. DAN 3. 3. Bangunan Zetro Jalan 9/27C. sila pastikan butir-butir adalah diisi dengan betul. 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. Bagi yang akan menduduki peperiksaan utama 3.1.2. Surat Sokongan yang jelas menyatakan kesusahan yang dialami oleh pelatih daripada Pesuruhjaya Sumpah. Surat pengesahan rasmi daripada pihak sekolah.2. 2.2.2.2.2. anda boleh membuat rayuan kepada Majlis Latihan Khidmat Negara dengan menggunakan Borang 3 (JLKN/P/:03/Pin2/10).1.2. sila hubungi:Jabatan Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian dan disahkan salinan sebenar. Penggawa.1. ditandatangani dan dilampirkan dengan dokumen yang lengkap iaitu: 3.1. 6. Komandan atau Pengetua Sekolah. Penggawa. ATAU Surat pengesahan rasmi daripada Lembaga Peperiksaan Malaysia. Penghulu.1. Isi borang dengan HANYA menggunakan huruf besar dan pen mata bola. 3. ATAU Salinan surat tawaran biasiswa dan disahkan salinan sebenar. Penghulu.2. Jaksa Pendamai. 3.2.1.2.1.2. Tok Sidang.2. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5/6 .2. Bangunan Zetro Jalan 9/27C. Salinan dokumen sokongan yang telah disahkan salinan sebenar.2.2.1. 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 dan disahkan salinan sebenar. tepat dan mudah dibaca.2. Majistret.1. Bagi memastikan pemprosesan segera permohonan tuan / puan. 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5.Arahan untuk Borang 1 (JLKN /P/:01/Pin 2/10) 1. Komandan atau Pengetua Sekolah. Bagi yang sedang meneruskan pengajian 3.2.3. 3. Untuk meluluskan permohonan anda.2. Institusi Pengajian Tinggi Awam (IPTA) 3. ATAU 3.3. Majistret.1. Institusi Pengajian Tinggi Swasta (IPTS) 3. ATAU Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi.3.

Penggawa. signed by the applicant and enclosed with all the required documents: 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 For further enquiries.2.2. Magistrate. 3. Commandant or School Principal. 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. The National Service Training Department reserves the right to reject application that is incomplete.3.1 Higher Educational Institution (Public) 3. Tok Sidang.2 4. 6.Instructions for Form 1 (JLKN/P/:01/Pin 2/10) 1. To ensure prompt process of your application. Bangunan Zetro Jalan 9/27C.3.3 Any other circumstances that will give rise to exceptional hardship 3.3 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. 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.1 A formal confirmation letter from a doctor Other exceptional hardship 3. OR 3.1. If your application is rejected. Commandant or School Principal certifying that the applicant is undergoing that particular hardship. Penghulu.2 A formal letter from the current school.2. Tok Sidang.2. Penggawa. OR A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.3.2. AND 3.1 3. 3.2 3. The appeal shall be addressed to :National Service Training Council Ministry of Defence Malaysia Aras 2-5.2 3. 3. Justice of Peace. AND A certified copy of the receipt (LATEST) proving payment of fees to the current Higher Educational Institution that the applicant is attending.3.1 A formal appeal letter certified by a Commissioner for Oath. please make sure that all details filled up are correct. To expedite this application.2. Justice of Peace. Bangunan Zetro Jalan 9/27C.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 3.2. please contact :National Service Training Department Ministry of Defence Malaysia Aras 2-5. OR A formal letter from the Examination Council of Malaysia 2. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. 3. All documents submitted to the National Service Training Department must be certified true copies by a Commissioner for Oath.2.2 A certified copy of any supporting documents proving that the applicant is undergoing that particular hardship.2.2.1 Currently pregnant 3.4 A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.1. accurate and legible.2. Magistrate.2. Penghulu. Kindly fill up this application form using ONLY block letters and ball point pen.1.1.1 3.2 Higher Educational Institution (Private) 3.2. 6/6 .1 For those that will be sitting for a major examination 3. For those who are pursuing studies 3.2.3. please make sure that this form is filled up completely.

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