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Borang an Penangguhan Borang 1

Borang an Penangguhan Borang 1

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

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

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

tepat dan mudah dibaca. Rayuan itu bolehlah dialamatkan kepada:Majlis Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5. Sedang hamil 3.1. sila hubungi:Jabatan Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5. Institusi Pengajian Tinggi Awam (IPTA) 3.3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5.2.2.2. Salinan dokumen sokongan yang dikemukakan kepada Jabatan Latihan Khidmat Negara hendaklah disahkan salinan sebenar oleh Pesuruhjaya Sumpah. Isi borang dengan HANYA menggunakan huruf besar dan pen mata bola. Majistret. Surat pengesahan rasmi daripada doktor.2. 3.2. Penghulu. Penghulu.4.2.2. Jaksa Pendamai.2. Komandan atau Pengetua Sekolah. 6.2. ATAU Salinan surat tawaran biasiswa dan disahkan salinan sebenar.3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5/6 .2. Lain-lain kesusahan luar biasa 3. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian dan disahkan salinan sebenar.2.1. Surat Sokongan yang jelas menyatakan kesusahan yang dialami oleh pelatih daripada Pesuruhjaya Sumpah.3. Jaksa Pendamai.3. 3. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian dan disahkan salinan sebenar. Bagi memastikan pemprosesan segera permohonan tuan / puan. ATAU Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi. Permohonan yang mengandungi maklumat yang tidak tepat atau tidak boleh dibaca tidak akan dilayan. 3.2. Bagi yang akan menduduki peperiksaan utama 3. Salinan dokumen sokongan yang telah disahkan salinan sebenar. ditandatangani dan dilampirkan dengan dokumen yang lengkap iaitu: 3.2. Komandan atau Pengetua Sekolah. Sekiranya permohonan pihak tuan / puan anda ditolak. Tok Sidang.3. Majistret. 3. Untuk makluman lanjut.2. Bangunan Zetro Jalan 9/27C.2.1. 4. DAN Salinan resit pembayaran yuran pengajian (TERKINI) yang telah dibayar (sekurang-kurangnya ½ daripada jumlah yuran sebenar) dan disahkan salinan sebenar.2.1.Arahan untuk Borang 1 (JLKN /P/:01/Pin 2/10) 1.1.2. 3. anda boleh membuat rayuan kepada Majlis Latihan Khidmat Negara dengan menggunakan Borang 3 (JLKN/P/:03/Pin2/10). 3. Apa-apa keadaan yang akan menimbulkan kesusahan luar biasa 3.1.1.2.2. Penggawa. Untuk meluluskan permohonan anda. ATAU 3.1. Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi.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. Surat pengesahan rasmi daripada pihak sekolah. sila pastikan Borang ini diisi dengan lengkap. ATAU Surat pengesahan rasmi daripada Lembaga Peperiksaan Malaysia.1.3. Bangunan Zetro Jalan 9/27C. 3. Tok Sidang.1.2. DAN 3.2. sila pastikan butir-butir adalah diisi dengan betul. 2. Institusi Pengajian Tinggi Swasta (IPTS) 3. Penggawa.3. 3. Bagi yang sedang meneruskan pengajian 3.1. 3.1.

1 3. 3.2.2.1. Penggawa. The National Service Training Department reserves the right to reject application that is incomplete.3 Any other circumstances that will give rise to exceptional hardship 3.2. AND 3.2.1 A formal appeal letter certified by a Commissioner for Oath.2. 3. Tok Sidang. All documents submitted to the National Service Training Department must be certified true copies by a Commissioner for Oath.2 4.1 3. Penggawa.2 3.1. 3. OR 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. Commandant or School Principal certifying that the applicant is undergoing that particular hardship. OR A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution. 6/6 . AND A certified copy of the receipt (LATEST) proving payment of fees to the current Higher Educational Institution that the applicant is attending.3. please contact :National Service Training Department Ministry of Defence Malaysia Aras 2-5.2 A certified copy of any supporting documents proving that the applicant is undergoing that particular hardship. Kindly fill up this application form using ONLY block letters and ball point pen.1 For those that will be sitting for a major examination 3. please make sure that all details filled up are correct. Justice of Peace.2. If your application is rejected.1 Currently pregnant 3.2. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur For further enquiries.2 A formal letter from the current school. OR A formal letter from the Examination Council of Malaysia 2.2.1 3.4 A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.2. For those who are pursuing studies 3.1 A formal confirmation letter from a doctor Other exceptional hardship 3. Penghulu.Instructions for Form 1 (JLKN/P/:01/Pin 2/10) 1. accurate and legible. Tok Sidang.1. Commandant or School Principal.2. 3. Justice of Peace. The appeal shall be addressed to :National Service Training Council Ministry of Defence Malaysia Aras 2-5.2 Higher Educational Institution (Private) 3. Magistrate.1 Higher Educational Institution (Public) 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.3. an appeal shall lie to the National Service Training Council by using form JLKN/P/:03/PIN 2/10. Magistrate. Bangunan Zetro Jalan 9/27C. Penghulu.2 3. signed by the applicant and enclosed with all the required documents: 3. To ensure prompt process of your application. Bangunan Zetro Jalan 9/27C.2. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5.2. 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.3.1. 6.3. 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. To expedite this application.2. please make sure that this form is filled up completely.3.2.

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