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

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

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

Tok Sidang.2. Tok Sidang. tepat dan mudah dibaca. Untuk makluman lanjut.4. Surat pengesahan rasmi daripada pihak sekolah. 3.1. 3. Institusi Pengajian Tinggi Awam (IPTA) 3. ATAU Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi.2.1.3. 3.2. Komandan atau Pengetua Sekolah.1. Permohonan yang mengandungi maklumat yang tidak tepat atau tidak boleh dibaca tidak akan dilayan. Komandan atau Pengetua Sekolah.3.2.1.2. Penghulu. Lain-lain kesusahan luar biasa 3. DAN Salinan resit pembayaran yuran pengajian (TERKINI) yang telah dibayar (sekurang-kurangnya ½ daripada jumlah yuran sebenar) dan disahkan salinan sebenar. ATAU 3.1.2.Arahan untuk Borang 1 (JLKN /P/:01/Pin 2/10) 1. Institusi Pengajian Tinggi Swasta (IPTS) 3.2. Bagi memastikan pemprosesan segera permohonan tuan / puan. 3. 3. Bagi yang sedang meneruskan pengajian 3.2.2. ATAU Surat pengesahan rasmi daripada Lembaga Peperiksaan Malaysia. sila pastikan butir-butir adalah diisi dengan betul. 6. Majistret.2.1. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. Jaksa Pendamai. Apa-apa keadaan yang akan menimbulkan kesusahan luar biasa 3. sila pastikan Borang ini diisi dengan lengkap. 3.1.2. 3. Bangunan Zetro Jalan 9/27C. Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi. Salinan dokumen sokongan yang telah disahkan salinan sebenar. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian dan disahkan salinan sebenar. Sedang hamil 3.1.1. Untuk meluluskan permohonan anda. Jaksa Pendamai. 2.2.1. DAN 3. 4.3.2.3. ATAU Salinan surat tawaran biasiswa dan disahkan salinan sebenar. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian dan disahkan salinan sebenar.1. Penggawa.2.2. 3. Bagi yang akan menduduki peperiksaan utama 3.2. anda boleh membuat rayuan kepada Majlis Latihan Khidmat Negara dengan menggunakan Borang 3 (JLKN/P/:03/Pin2/10).2.3. ditandatangani dan dilampirkan dengan dokumen yang lengkap iaitu: 3. 3. Rayuan itu bolehlah dialamatkan kepada:Majlis Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5.2. 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. sila hubungi:Jabatan Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5/6 . Penghulu. Majistret. Penggawa.2.3. Bangunan Zetro Jalan 9/27C. Salinan dokumen sokongan yang dikemukakan kepada Jabatan Latihan Khidmat Negara hendaklah disahkan salinan sebenar oleh Pesuruhjaya Sumpah.2.2.1. Sekiranya permohonan pihak tuan / puan anda ditolak.1. Isi borang dengan HANYA menggunakan huruf besar dan pen mata bola. Surat pengesahan rasmi daripada doktor.3. Surat Sokongan yang jelas menyatakan kesusahan yang dialami oleh pelatih daripada Pesuruhjaya Sumpah.

Tok Sidang.1. Magistrate.2 3. For those who are pursuing studies 3. please make sure that all details filled up are correct.2.2.1. Kindly fill up this application form using ONLY block letters and ball point pen. Tok Sidang.3 Any other circumstances that will give rise to exceptional hardship 3.2. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur For further enquiries. OR A formal letter from the Examination Council of Malaysia 2. OR 3. Penghulu.3.3.1 3. 3.2 A certified copy of any supporting documents proving that the applicant is undergoing that particular hardship. Bangunan Zetro Jalan 9/27C.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. accurate and legible.2.3. 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. 3. Commandant or School Principal certifying that the applicant is undergoing that particular hardship. 3.1 3. signed by the applicant and enclosed with all the required documents: 3. Penggawa. The appeal shall be addressed to :National Service Training Council Ministry of Defence Malaysia Aras 2-5.2 A formal letter from the current school. please make sure that this form is filled up completely.3.2.2 4. Justice of Peace.2. To expedite this application.1 3.Instructions for Form 1 (JLKN/P/:01/Pin 2/10) 1.1. The National Service Training Department reserves the right to reject application that is incomplete.2.1 A formal confirmation letter from a doctor Other exceptional hardship 3. To ensure prompt process of your application. Justice of Peace. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5.2. Commandant or School Principal.1 Currently pregnant 3.2.2. 3. Penghulu. an appeal shall lie to the National Service Training Council by using form JLKN/P/:03/PIN 2/10. 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 Higher Educational Institution (Public) 3. OR A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.2 Higher Educational Institution (Private) 3. All documents submitted to the National Service Training Department must be certified true copies by a Commissioner for Oath.4 A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution. AND A certified copy of the receipt (LATEST) proving payment of fees to the current Higher Educational Institution that the applicant is attending.2.1 A formal appeal letter certified by a Commissioner for Oath.1 For those that will be sitting for a major examination 3. please contact :National Service Training Department Ministry of Defence Malaysia Aras 2-5. AND 3. 6/6 .1.2.1.2 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.3.2 3. If your application is rejected. 6.2.2. Magistrate. Bangunan Zetro Jalan 9/27C. Penggawa.

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