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

........................ 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......... 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): …………………………………………………………………………....................3.... 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.......): .....

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

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

2. Majistret. Salinan dokumen sokongan yang telah disahkan salinan sebenar. Sedang hamil 3.3.2. sila pastikan butir-butir adalah diisi dengan betul. Komandan atau Pengetua Sekolah.2.1.2.1. 2. Lain-lain kesusahan luar biasa 3.Arahan untuk Borang 1 (JLKN /P/:01/Pin 2/10) 1.2. Bangunan Zetro Jalan 9/27C. 3. Penghulu.2. ditandatangani dan dilampirkan dengan dokumen yang lengkap iaitu: 3.1.1. 3.2.2. Bagi yang akan menduduki peperiksaan utama 3. Institusi Pengajian Tinggi Awam (IPTA) 3.3. Sekiranya permohonan pihak tuan / puan anda ditolak. Permohonan yang mengandungi maklumat yang tidak tepat atau tidak boleh dibaca tidak akan dilayan. sila pastikan Borang ini diisi dengan lengkap.1. Majistret. Surat pengesahan rasmi daripada doktor. ATAU Surat pengesahan rasmi daripada Lembaga Peperiksaan Malaysia.2.3. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian dan disahkan salinan sebenar.3.2. anda boleh membuat rayuan kepada Majlis Latihan Khidmat Negara dengan menggunakan Borang 3 (JLKN/P/:03/Pin2/10). Bangunan Zetro Jalan 9/27C. tepat dan mudah dibaca. 6.2. Salinan dokumen sokongan yang dikemukakan kepada Jabatan Latihan Khidmat Negara hendaklah disahkan salinan sebenar oleh Pesuruhjaya Sumpah. 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5/6 .1.1. Komandan atau Pengetua Sekolah. 3. Bagi memastikan pemprosesan segera permohonan tuan / puan. sila hubungi:Jabatan Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5. Penghulu. Jaksa Pendamai. ATAU Salinan surat tawaran biasiswa dan disahkan salinan sebenar.2.2. 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.2.2. ATAU 3. 3. 3. Bagi yang sedang meneruskan pengajian 3.3. Surat pengesahan rasmi daripada pihak sekolah.1. Penggawa. 4.1.2. Institusi Pengajian Tinggi Swasta (IPTS) 3. DAN Salinan resit pembayaran yuran pengajian (TERKINI) yang telah dibayar (sekurang-kurangnya ½ daripada jumlah yuran sebenar) dan disahkan salinan sebenar.2. ATAU Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi.2. DAN 3. Jaksa Pendamai.1. Rayuan itu bolehlah dialamatkan kepada:Majlis Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5. 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. Untuk meluluskan permohonan anda. 3.1.4. 3. Penggawa.2. Tok Sidang.1.3. Untuk makluman lanjut. 3. Apa-apa keadaan yang akan menimbulkan kesusahan luar biasa 3. Tok Sidang. Isi borang dengan HANYA menggunakan huruf besar dan pen mata bola. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5.3. Surat Sokongan yang jelas menyatakan kesusahan yang dialami oleh pelatih daripada Pesuruhjaya Sumpah.1.2.

Magistrate. OR A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.2. Tok Sidang. For those who are pursuing studies 3. AND A certified copy of the receipt (LATEST) proving payment of fees to the current Higher Educational Institution that the applicant is attending.1 3.1. Justice of Peace. 3.3. 3.2.1. All documents submitted to the National Service Training Department must be certified true copies by a Commissioner for Oath. an appeal shall lie to the National Service Training Council by using form JLKN/P/:03/PIN 2/10. Commandant or School Principal certifying that the applicant is undergoing that particular hardship. If your application is rejected. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. 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.2. Bangunan Zetro Jalan 9/27C. Commandant or School Principal.3 Any other circumstances that will give rise to exceptional hardship 3.2 4.2 A certified copy of any supporting documents proving that the applicant is undergoing that particular hardship. 3. Bangunan Zetro Jalan 9/27C.2.2. Penggawa.2.2 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.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 For those that will be sitting for a major examination 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur For further enquiries. 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. Kindly fill up this application form using ONLY block letters and ball point pen. Penggawa.1.2.2. OR A formal letter from the Examination Council of Malaysia 2.3.1 Currently pregnant 3. To expedite this application.2. OR 3. AND 3.3.1 3.2. signed by the applicant and enclosed with all the required documents: 3. Penghulu. 6/6 .1 3. accurate and legible.3.2 A formal letter from the current school.1 A formal confirmation letter from a doctor Other exceptional hardship 3.2 Higher Educational Institution (Private) 3. Magistrate. 6.1.2 3. Tok Sidang.1 Higher Educational Institution (Public) 3. please make sure that all details filled up are correct.1.Instructions for Form 1 (JLKN/P/:01/Pin 2/10) 1. The National Service Training Department reserves the right to reject application that is incomplete.2. please contact :National Service Training Department Ministry of Defence Malaysia Aras 2-5.4 A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution. The appeal shall be addressed to :National Service Training Council Ministry of Defence Malaysia Aras 2-5.2.2. 3. Justice of Peace.3.2. To ensure prompt process of your application. please make sure that this form is filled up completely. Penghulu.1 A formal appeal letter certified by a Commissioner for Oath.