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

....................... Rujukan (Reference 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....... 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.............3......... 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 ....................

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

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

2.2. Tok Sidang.3. 3. Bagi yang akan menduduki peperiksaan utama 3. ATAU Salinan surat tawaran biasiswa dan disahkan salinan sebenar. DAN Salinan resit pembayaran yuran pengajian (TERKINI) yang telah dibayar (sekurang-kurangnya ½ daripada jumlah yuran sebenar) dan disahkan salinan sebenar. Jaksa Pendamai.2. Rayuan itu bolehlah dialamatkan kepada:Majlis Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5.2.1.1. Sekiranya permohonan pihak tuan / puan anda ditolak.1.1. Bangunan Zetro Jalan 9/27C.2.2. Sedang hamil 3. Majistret.2.3. 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.Arahan untuk Borang 1 (JLKN /P/:01/Pin 2/10) 1. Majistret. Bagi memastikan pemprosesan segera permohonan tuan / puan. sila pastikan butir-butir adalah diisi dengan betul. Apa-apa keadaan yang akan menimbulkan kesusahan luar biasa 3. 3.3.2. DAN 3. anda boleh membuat rayuan kepada Majlis Latihan Khidmat Negara dengan menggunakan Borang 3 (JLKN/P/:03/Pin2/10). Bagi yang sedang meneruskan pengajian 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5/6 . 3. ATAU Surat pengesahan rasmi daripada Lembaga Peperiksaan Malaysia. 3. 3.1.2. Penghulu. Komandan atau Pengetua Sekolah. ATAU Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi.2. Penghulu. 3. 3.2. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian dan disahkan salinan sebenar. 3. Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi. Salinan dokumen sokongan yang telah disahkan salinan sebenar. Untuk makluman lanjut.2. Jaksa Pendamai.2. Penggawa. Surat pengesahan rasmi daripada doktor. Komandan atau Pengetua Sekolah. sila pastikan Borang ini diisi dengan lengkap.3.2. 2. Surat pengesahan rasmi daripada pihak sekolah.2. Surat Sokongan yang jelas menyatakan kesusahan yang dialami oleh pelatih daripada Pesuruhjaya Sumpah.2.1. Untuk meluluskan permohonan anda.2. Penggawa.1.1.4. Bangunan Zetro Jalan 9/27C. sila hubungi:Jabatan Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5.3. Lain-lain kesusahan luar biasa 3. ATAU 3. Institusi Pengajian Tinggi Awam (IPTA) 3. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian dan disahkan salinan sebenar.1. Institusi Pengajian Tinggi Swasta (IPTS) 3. 4. 6.2. Isi borang dengan HANYA menggunakan huruf besar dan pen mata bola.3.2.2. ditandatangani dan dilampirkan dengan dokumen yang lengkap iaitu: 3.1. 3.3. tepat dan mudah dibaca. Salinan dokumen sokongan yang dikemukakan kepada Jabatan Latihan Khidmat Negara hendaklah disahkan salinan sebenar oleh Pesuruhjaya Sumpah.1. Tok Sidang. Permohonan yang mengandungi maklumat yang tidak tepat atau tidak boleh dibaca tidak akan dilayan. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5.1.1.2.

6.2 4.3. an appeal shall lie to the National Service Training Council by using form JLKN/P/:03/PIN 2/10.1 3. All documents submitted to the National Service Training Department must be certified true copies by a Commissioner for Oath. Tok Sidang.2. Magistrate.1. Magistrate. Penghulu. 6/6 . accurate and legible.1 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. 3.2. The appeal shall be addressed to :National Service Training Council Ministry of Defence Malaysia Aras 2-5. To expedite this application.2. OR A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.2.2 3. Penggawa.3.2.2 A certified copy of any supporting documents proving that the applicant is undergoing that particular hardship.1. please contact :National Service Training Department Ministry of Defence Malaysia Aras 2-5.2. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur For further enquiries. Penghulu.2.1 3. To ensure prompt process of your application. Kindly fill up this application form using ONLY block letters and ball point pen. The National Service Training Department reserves the right to reject application that is incomplete. Commandant or School Principal.4 A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution. 3. 3. Justice of Peace.1.2 3.1. OR A formal letter from the Examination Council of Malaysia 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 appeal letter certified by a Commissioner for Oath. please make sure that all details filled up are correct.2. Commandant or School Principal certifying that the applicant is undergoing that particular hardship.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. Bangunan Zetro Jalan 9/27C. For those who are pursuing studies 3.3.2. please make sure that this form is filled up completely. OR 3.3 Any other circumstances that will give rise to exceptional hardship 3.1.1 For those that will be sitting for a major examination 3. Bangunan Zetro Jalan 9/27C. AND 3.3. Tok Sidang.3.Instructions for Form 1 (JLKN/P/:01/Pin 2/10) 1.2 Higher Educational Institution (Private) 3. Penggawa.2. If your application is rejected.2. signed by the applicant and enclosed with all the required documents: 3.1 A formal confirmation letter from a doctor Other exceptional hardship 3.1 Currently pregnant 3. Justice of Peace.2.2.2 A formal letter from the current school.2. AND A certified copy of the receipt (LATEST) proving payment of fees to the current Higher Educational Institution that the applicant is attending.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. 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.

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