Lampiran 1

APM/LANTIK/KEHORMAT/BERSEKUTU/PA/100-1/4/6
Tarikh Borang Diterima PPAD :
Tarikh Borang Diterima PPAN:
Tarikh Borang Diterima BPA, IPPA:
Kategori:
Lembaga:

PERMOHONAN UNTUK LANTIKAN SEBAGAI

PEGAWAI KEHORMAT/ PEGAWAI BERSEKUTU
PERTAHANAN AWAM MALAYSIA

GAMBAR
TERBARU
(WARNA)
BERUKURAN
PASPORT

1. Nama Penuh ( Huruf Besar ) : ........................................................................................................

(Berserta gelaran: Cth Prof. Datuk Dr Ir Aziz Bin Buang)

2. No. Kad Pengenalan ( * ) : ........................................................................................................

3. Tarikh Lahir : ........................................................................................................

4. Umur Sekarang : ........................................................................................................

5. Kelulusan Tertinggi ( * ) : .......................................................................................................

6. Jawatan sekarang : .......................................................................................................

7. Gred : ........................................................................................................

8. Pendapatan sebulan ( RM ) : ......................................................................................................

9. Alamat Tempat Kerja : ........................................................................................................

........................................................................................................

Poskod ..........................................................................................

10. No. Telefon Pejabat : .......................................................................................................

11. No. Faksimili : ………………………………………………………………………….

12. No. Telefon Bimbit : ………………………………………………………………………….

13. Alamat Rumah : ......................................................................................................

.......................................................................................................

Poskod ........................................................................................

14. No. Telefon Rumah : .......................................................................................................

15. Alamat Emel : .......................................................................................................

16. Hobi / Kegemaran : 1. ................................................................................................

2. ................................................................................................

3. ................................................................................................

17. Penglibatan Dengan Badan : 1. ................................................................................................

Sukarela lain masa kini, dan 2. ..........................................................................................

Jawatannya sekali jika ada. 3. ................................................................................................

18. Pingat Kebesaran Negeri / Negara

Yang Diterima 1. Tahun : ...……………. Jenis Pingat : ………………… Negeri : ………………

2. Tahun : ...……………. Jenis Pingat : ………………… Negeri : ………………

3. Tahun : ...……………. Jenis Pingat : ………………… Negeri : ……………..

4. Tahun : ...……………. Jenis Pingat : ………………… Negeri : ………………

19. Terangkan sebab anda ingin menjadi Pegawai Bersekutu dan nyatakan sumbangan yang telah
anda berikan kepada masyarakat melalui Pasukan Pertahanan Awam

Sebab-sebab:

..................................................................................................................................................................

..................................................................................................................................................................

..................................................................................................................................................................

Sumbangan :

1. ...........................................................................................................................................................

2. ...........................................................................................................................................................

3. ...........................................................................................................................................................
20. Negeri / Cawangan Yang Ingin Disertai : .......................................................................................

21. Saya mengaku bahawa segala butir-butir yang diberikan di atas adalah benar.

Tarikh : T/Tangan : .....................................................

( Nama : )

Cop Syarikat :

22. Pengesahan / Perakuan Majikan

Disahkan bahawa penama di atas adalah seorang ................................................................................

( Gelaran Jawatan ) di Syarikat ...............................................................................................................

Mulai ....................................................................

Tarikh : T/Tangan : ..........................................................

( Nama : )

Cop Syarikat :

CATATAN :

 ( * ) Perlu disertakan salinan.

 Gambar berukuran passport WAJIB disertakan.
 Sila isikan maklumat ( perkara 1-22) dengan LENGKAP dan JELAS bagi
memudahkan penilaian dibuat.
 Sila sertakan dokumen sokongan yang berkaitan
 ULASAN DAN SOKONGAN
DAERAH :……………………………… NEGERI :…………………………….

1. Ulasan PPAD : ...........................................................................................................

...........................................................................................................

...........................................................................................................

...........................................................................................................

Tarikh : T/Tangan : .....................................................

( Cop Rasmi : )

2. Ulasan PPAN : .............................................................................................................

.............................................................................................................

.............................................................................................................

.............................................................................................................

3. Disokong / Tidak disokong ( * )

4. Jika disokong – Gred Pangkat Yang Dicadangkan ( * ) : ..........................................................

5. Asas-asas pertimbangkan cadangan pangkat :

.............................................................................................................................................................

.............................................................................................................................................................

Tarikh : T/Tangan : .....................................................

( Cop Rasmi : )

Keputusan Ketua Pengarah Pertahanan Awam :

Saya bersetuju / tidak bersetuju ( * ) dengan cadangan

Tarikh : ……………………….. ………………………………………

T / Tangan Ketua Pengarah & Cop
( * ) potong yang tidak berkenaan