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......... 4............3.): ........ 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): ………………………………………………………………………….... Rujukan (Reference 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 ...

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

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

1. ATAU 3. Isi borang dengan HANYA menggunakan huruf besar dan pen mata bola. 3.1. 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.2.2. 3. Apa-apa keadaan yang akan menimbulkan kesusahan luar biasa 3. Tok Sidang.2.1. Penghulu. Institusi Pengajian Tinggi Awam (IPTA) 3.3.1.2. Bangunan Zetro Jalan 9/27C.3. Penggawa. Jaksa Pendamai. Sedang hamil 3.2.1.1. Untuk meluluskan permohonan anda.4.1.2.1.2. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian dan disahkan salinan sebenar.2.2. Rayuan itu bolehlah dialamatkan kepada:Majlis Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5.Arahan untuk Borang 1 (JLKN /P/:01/Pin 2/10) 1.2. Jaksa Pendamai. 3.3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5.2.2.2. Institusi Pengajian Tinggi Swasta (IPTS) 3.2. Surat pengesahan rasmi daripada pihak sekolah. Bagi memastikan pemprosesan segera permohonan tuan / puan. Salinan dokumen sokongan yang dikemukakan kepada Jabatan Latihan Khidmat Negara hendaklah disahkan salinan sebenar oleh Pesuruhjaya Sumpah. Lain-lain kesusahan luar biasa 3. Bagi yang sedang meneruskan pengajian 3. Permohonan yang mengandungi maklumat yang tidak tepat atau tidak boleh dibaca tidak akan dilayan. Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi. Bagi yang akan menduduki peperiksaan utama 3. Majistret. sila pastikan Borang ini diisi dengan lengkap. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5/6 .1. anda boleh membuat rayuan kepada Majlis Latihan Khidmat Negara dengan menggunakan Borang 3 (JLKN/P/:03/Pin2/10). Surat Sokongan yang jelas menyatakan kesusahan yang dialami oleh pelatih daripada Pesuruhjaya Sumpah. Surat pengesahan rasmi daripada doktor. Sekiranya permohonan pihak tuan / puan anda ditolak.3.1. DAN 3. 4. 2. 3. Komandan atau Pengetua Sekolah.2. Tok Sidang.1. 3. sila pastikan butir-butir adalah diisi dengan betul. Penggawa.2. 3. sila hubungi:Jabatan Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5. ditandatangani dan dilampirkan dengan dokumen yang lengkap iaitu: 3.3.1. ATAU Salinan surat tawaran biasiswa dan disahkan salinan sebenar. Majistret. Untuk makluman lanjut. 3. Komandan atau Pengetua Sekolah. Salinan dokumen sokongan yang telah disahkan salinan sebenar. ATAU Surat pengesahan rasmi daripada Lembaga Peperiksaan Malaysia. 6. tepat dan mudah dibaca. 3.2.2. ATAU Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi. Penghulu.2.1. 3.3. DAN Salinan resit pembayaran yuran pengajian (TERKINI) yang telah dibayar (sekurang-kurangnya ½ daripada jumlah yuran sebenar) dan disahkan salinan sebenar.2.2.3. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian dan disahkan salinan sebenar. Bangunan Zetro Jalan 9/27C.

1. Commandant or School Principal.2 Higher Educational Institution (Private) 3. 3. All documents submitted to the National Service Training Department must be certified true copies by a Commissioner for Oath.1 A formal appeal letter certified by a Commissioner for Oath. The appeal shall be addressed to :National Service Training Council Ministry of Defence Malaysia Aras 2-5.2.1 For those that will be sitting for a major examination 3.2.2.1 3. Tok Sidang. Commandant or School Principal certifying that the applicant is undergoing that particular hardship.1 Currently pregnant 3. 6.3 Any other circumstances that will give rise to exceptional hardship 3. Justice of Peace.1. 3. AND A certified copy of the receipt (LATEST) proving payment of fees to the current Higher Educational Institution that the applicant is attending. 3.2.3.2.2. please make sure that this form is filled up completely.3.2 A certified copy of any supporting documents proving that the applicant is undergoing that particular hardship.2. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. Penghulu. Penggawa.1. Magistrate.1 3.2.2 4. 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. Justice of Peace. Penghulu.Instructions for Form 1 (JLKN/P/:01/Pin 2/10) 1. an appeal shall lie to the National Service Training Council by using form JLKN/P/:03/PIN 2/10.3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur For further enquiries. Tok Sidang. To ensure prompt process of your application.1 3.1.2 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. The National Service Training Department reserves the right to reject application that is incomplete. Bangunan Zetro Jalan 9/27C. 3. Magistrate. OR A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.3. please contact :National Service Training Department Ministry of Defence Malaysia Aras 2-5. OR A formal letter from the Examination Council of Malaysia 2.2. please make sure that all details filled up are correct.2. accurate and legible.1. Kindly fill up this application form using ONLY block letters and ball point pen. If your application is rejected.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. To expedite this application. For those who are pursuing studies 3.2 3.2 A formal letter from the current school. 6/6 . Bangunan Zetro Jalan 9/27C.2. 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.4 A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.2. signed by the applicant and enclosed with all the required documents: 3. Penggawa.2 3.2.1 A formal confirmation letter from a doctor Other exceptional hardship 3.1 Higher Educational Institution (Public) 3. AND 3.3. OR 3.2.

Sign up to vote on this title
UsefulNot useful