LAMPIRAN

KOR KADET POLIS

POLIS DIRAJA MALAYSIA

PENYATA DIRI

1. Kontinjen ..................................................................................................................

2. Daerah Polis ............................................................................................................

3. Nama .......................................................................................................................

4. Nombor Polis Bantuan .............................................................................................

5. Nombor Kad Pengenalan(baru) .................................... (lama) ..............................

6. Nama Bapa ..............................................................................................................

7. Tempat & Tarikh Lahir ..............................................................................................

8. Alamat ......................................................................................................................

9. No. Telefon ...............................................................................................................

10. Pekerjaan .................................................................................................................

11. Majikan dan Alamat .................................................................................................

12. Gaji Hakiki ................................................................................................................

13. Kelulusan ………………………………………….......................................................

14. Taraf Perkahwinan ...................................................................................................

15. Nama & Alamat Suami/Isteri ……………………………….....................................

..................................................................................................................................
16. Waris & Alamat (selain bil. 14):-

i ...........................................................................................................................

Persaudaraan ..........................................................................................................

ii ...........................................................................................................................

Persaudaraan ..........................................................................................................

iii ........................................................................................................................

Persaudaraan ..........................................................................................................

Saya mengaku bahawa setakat yang saya ketahui,butir-butir yang tersebut

diatas semuanya adalah benar.

Tarikh: ................... ...................……

(Tandatangan)

Saksi:

Tandatangan: ...........................................

Nama: ......................................................

Pangkat: ..................................................

Jawatan: .................................................