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1 MALAYSIA GLOBALLY RECOGNISED INDUSTRY AND

PROPFESIONAL CERTIFICATION
(1 MALAYSIAGRIP)
Permohonan kursus Semakan Kelulusan
NIOSH dan PSMB PSMB
Kursus yang ditawarkan : Dokumen yang
Borang yang Pihak NIOSH akan
Pegawai Keselamatan dan dilampirkan perlu membuat semakan
diperlukan
Salinan Mykad,
Kesihatan (SHO) diisi dan diserahkan untuk kelayakan salinan slip gaji
terkini, dan salinan
NIOSH PSMB
sijil akademik
Tarikh : 01-30/11/2016
Tempoh : 22 hari
Yuran kursus : Pembiayaan sepenuhnya oleh Pendaftaran Menghadiri kursus
1 MALAYSIAGRIP* Peperiksaan SHO Menghadiri kursus
Mendaftar 22 hari setelah
Syarat kelayakan peperiksaan setelah mendapat
< 2000 - SPM Gred 3 atau tamat kursus kelulusan
> 2000 - Minimum SPM kredit6C B.Melayu,
B.Inggeris, Matematik Lulus 8E Sains dan 2
Matapelajaran lain atau
Diploma keatas dan
Majikan perlu berdaftar dengan PSMB dan Bengkel Menduduki
Pekerja perlu mendapatkan kelulusan Perlu menghadiri peperiksaan
majikan Kursus bengkel Perlu menjawab 4
sebelum kertas ujian
Kumpulan sasaran peperiksaan
Pekerja warganegara Malaysia yang ingin
meningkatkan taraf pendidikan
Mempunyai pengalaman dalam Sebarang Pertanyaan boleh menghubungi kami di:
pengurusan Projek
Tel : 03 8911 3973/3974
Permohonan adalah berpandukan
Email :ercd.niosh@gmail.com
kelulusan dari pihak PSMB
Website : www.niosh.com.my
NIOSH-A46P31-T Rev 6

INSTITUT KESELAMATAN DAN KESIHATAN PEKERJAAN NEGARA


NATIONAL INSTITUTE OF OCCUPATIONAL SAFETY AND HEALTH (243042-U)
BORANG PERMOHONAN KURSUS
COURSE APPLICATION FORM
TEL : 03 - 8911 3800 FAX : 03 - 8926 3900 URL : www.niosh.com.my
TAJUK KURSUS COURSE TITLE TARIKH KURSUS COURSE DATE

A. MAKLUMAT PEMOHON APPLICANTS INFORMATION

NAMA
NAME

NAMA DI ATAS KAD UMUR


HOLDER NAME AGE

MYKAD/ PASPORT TARIKH LAHIR


MYKAD/ PASSPORT DATE of BIRTH

JANTINA PEREMPUAN LELAKI


GENDER FEMALE MALE

ALAMAT SURAT-
MENYURAT
MAILING ADDRESS

BANDAR
CITY

POSKOD NEGERI
POSTCODE STATE

KELAYAKAN TERTINGGI SPM/ MCE SPMV DIPLOMA


HIGHEST QUALIFICATION

IJAZAH SARJANA MUDA IJAZAH SARJANA DOKTOR FALSAFAH (PhD)


BACHELORS DEGREE MASTERS DEGREE DOCTOR of PHILOSOPHY (PhD)

LAIN-LAIN, NYATAKAN
OTHERS, PLEASE SPECIFY

BIDANG PENGAJIAN
FIELD OF STUDY

JAWATAN SEMASA
CURRENT POSITION

NO. TELEFON NO. FAKSIMILI


TELEPHONE NO. FACSIMILE NO.

NO. TEL. BIMBIT E-MEL


HANDPHONE NO. E-MAIL

IMMEDIATE FAMILY RELATION


WARIS TERDEKAT HUBUNGAN

EMERGENCY CONTACT NO.


NO UNTUK DIHUBUNGI

B. MAKLUMAT PENAJAAN SPONSORS INFORMATION

PENAJA SPONSOR TAJAAN SENDIRI TAJAAN SYARIKAT


SELF-SPONSORED COMPANY SPONSORED

NAMA
NAME

ALAMAT SURAT-
MENYURAT
MAILING ADDRESS

BANDAR
CITY

POSKOD NEGERI
POSTCODE STATE

PEGAWAI BERTUGAS
PERSON IN-CHARGE

JAWATAN
DESIGNATION

NO. TELEFON
TELEPHONE NO.
JENIS INDUSTRI (PILIH SALAH SATU)
TYPE OF INDUSTRY (TICK ONE)

PEMBUATAN PERLOMBONGAN & KUARI HOTEL & RESTORAN


MANUFACTURING MINING & QUARRYING HOTEL & RESTAURANT

PEMBINAAN PEMBORONG & PERUNCITAN PENGANGKUTAN, GUDANG & KOMUNIKASI


CONSTRUCTION WHOLESALE & RETAIL TRADE TRANSPORTATION, WAREHOUSE & COMMUNICATION

PERKHIDMATAN AWAM & PENGUATKUASAAN PERTANIAN, PERHUTANAN & PERIKANAN


PUBLIC SERVICE & AUTHORITY AGRICULTURE, FORESTRY & AQUACULTURE

KEWANGAN, INSURAN, HARTANAH & PERKHIDMATAN PERNIAGAAN


FINANCE, INSURANCE, REAL ESTATES & BUSINESS SERVICE

UTILITI (ELEKTRIK, GAS, AIR & PERKHIDMATAN PENJAGAAN KEBERSIHAN)


UTILITIES (ELECTRICITY, GAS, WATER & SANITARY SERVICE)

LAIN-LAIN : NYATAKAN
OTHERS : SPECIFY

COP RASMI SYARIKAT


COMPANY OFFICAL STAMP

TANDATANGAN
SIGNATURE

TARIKH
DATE

C. MAKLUMAT KEAHLIAN MEMBERSHIP INFORMATION


KEAHLIAN NIOSH YA TIDAK JIKA YA PERSEORANGAN KORPORAT
NIOSH MEMBERSHIP YES NO IF YES INDIVIDUAL CORPORATE

NO. KEAHLIAN TARIKH KEAHLIAN


MEMBERSHIP NO. DATE OF MEMBERSHIP

D. MAKLUMAT PEMBAYARAN PAYMENT INFORMATION

HARGA KURSUS
COURSE FEE R M . 0 0

KAEDAH PEMBAYARAN TUNAI KIRIMAN WANG DRAF BANK PESANAN KERAJAAN (LO)
PAYMENT METHOD CASH MONEY ORDER BANK DRAFT LOCAL ORDER (LO)

KAD KREDIT BAYARAN SECARA ONLINE (MAYBANK2U)


CREDIT CARD ONLINE PAYMENT (MAYBANK2U)

CEK NO. CEK


CHEQUE CHEQUE NO.

TANDATANGAN
TARIKH
PEMOHON DATE
APPLICANTS SIGNATURE

D. PENTING IMPORTANT
1. Sila pastikan cek dibayar atas nama NIOSH. No. akaun NIOSH : 5122 6840 2410 (Maybank, Cawangan Bandar Baru Bangi).
Please ensure that cheque is payable to NIOSH . NIOSH account no : 5122 6840 2410 (Maybank, Bandar Baru Bangi Branch).

2. Jangan hantarkan wang tunai menerusi pos.


Do not send cash through mail.

3. NIOSH berhak untuk menolak permohonan yang tidak lengkap.


NIOSH has the right to reject incomplete application.

SILA HANTARKAN BORANG PERMOHONAN YANG TELAH LENGKAP KEPADA :


PLEASE SEND COMPLETE APPLICATION FORM TO :

Ibu Pejabat NIOSH, (Selangor) Pejabat Wilayah Utara (P.Pinang) Pejabat Wilayah Pantai Timur (Kemaman)

Tel : 03 - 8911 3815/ 3819 (HETD) Tel : 04 - 380 1200 Tel : 09 - 859 9961/ 62
Faks : 03 - 8926 3900 (HETD) Faks : 04 - 397 3977 Faks : 09 - 859 9960
E-mel : training@niosh.com.my E-mel : penang@niosh.com.my E-mel : terengganu@niosh.com.my

Pejabat Wilayah Selatan Pejabat Wilayah Sarawak Pejabat Wilayah Sabah

Tel : 07 - 599 1200 (Johor) Tel : 086 - 311 500/ 330 600 (Bintulu) Tel : 088 - 264 252 (Kota Kinabalu)
: 06 - 232 6855/ 66 (Melaka) : 082 - 256 500/ 241 800 (Kuching) : 087 - 423 254/ 408 778 (Labuan)
: 085 - 406 085/ 071 (Miri)
Faks : 07 - 599 0200 (Johor) Faks : 086 - 315 501 (Bintulu) Faks : 088 - 263 252 (Kota Kinabalu)
: 06 - 232 6805 (Melaka) : 082 - 253 020 (Kuching) :087 - 423 255 (Labuan)
E-mel : johor@niosh.com.my : 085 - 406 086 (Miri) E-mel : sabah@niosh.com.my
: melaka@niosh.com.my E-mel : sarawak@niosh.com.my
PSMB/GRIP/1/15

1MALAYSIA GLOBALLY RECOGNISED INDUSTRY AND PROFESSIONAL


CERTIFICATION
(1MALAYSIAGRIP)

APPLICATION FORM

CATEGORY OF EMPLOYEE

Employee of HRDF Registered Employer

Employee of Non Registered Employer with HRDF

Please tick () where applicable

SUPPORTING DOCUMENTS TO BE ATTACHED

Copy of MyID (Identity Card)

Copy of Latest 1 Month Pay Slip

Please tick ()

A. TRAINING INFORMATION

1 Course Title :

2 Start Date :

3 Completion Date :

4 Venue :

5 Training Provider :

1
B) TRAINEE INFORMATION

1 Name :

2 MyID Card No. : - -

3 Gender : Male Female

4 Address :

Postcode State:

5 Tel. No (Office) :

6 Tel. No (Handphone) :

7 Email :

8 Social Media : LinkedIn : ..


Preference (please
Facebook : ..
provide ID)
Others : ..
9 Academic : Sijil Pelajaran Malaysia (SPM)
Qualification
Sijil Tinggi Pelajaran Malaysia (STPM)

Certificate / Skills Certificate

Diploma

Bachelor Degree

Master Degree

Doctoral Degree

Others:

10 Specify Highest :
Academic
Qualification;
eg. Bachelor of Economics

2
11 Current Position : Manager Professional Technicians & Associate

Clerical Support Workers Service and Sales Workers

Skilled Agricultural, Forestry & Fishery Workers

Craft and Related Trades Elementary Occupations

Plant and Machine Operators and Assemblers

12 Exact Position :

13 Current Monthly : Below RM800 for Sabah and Sarawak


Salary Range Below RM900 for Peninsular Malaysia
RM800 to RM1,999 for Sabah & Sarawak

RM900 to RM1,999 for Sabah & Sarawak

RM900 to RM1,999 Peninsular Malaysia

RM2,000 to RM3,999

RM4,000 to RM5,999

RM6,000 to RM7,999

RM8,000 to RM9,999

RM10,000 and above

(C) EMPLOYER INFORMATION

1 Name of Employer :

2 MyCoID (Company :
Registration Number)
- Compulsory
3 Industry : Manufacturing Service Agriculture

Construction Mining & Quarrying

Specify Sub sector:

4 Address :

Poscode State

3
5 Tel. No (Office) :

6 Fax . No. :

7 Contact Person (HR) :

8 HR Email Address :

D. EMPLOYER ENDORSEMENT

I hereby declare that the above mentioned trainee is an employee of our company

Signature : ............................................. Company Stamp:

Name : .

Position : ..

Date : .......

E. EMPLOYEE ENDORSEMENT

I declare that the facts stated in this application and the accompanying information are true and correct and
I have not withheld / distorted any material fact.

Signature : ...........................................

Name :

MyID Card No. :

Date : ...