LAMPIRAN C

BORANG PENDAFTARAN PEKERJA DOMESTIK

DOMESTIC WORKER’S REGISTRATION FORM

A. BUTIR-BUTIR PEKERJA DOMESTIK / PARTICULARS OF DOMESTIC WORKER

A1. Nama *
Name

A2. Warganegara* ________________________________________ A3. Tarikh lahir *

Nationality Date of Birth Hari Bulan Tahun
Day Month Year
A4. Jenis Pekerjaan ________________________________________ A5. Jantina * Lelaki Perempuan
Type of Occupation Gender Male Female
A6. Alamat tempat tinggal * ______________________________________________________________________________________________
Residential Address
_____________________________________________________________________________________________
A7. No. Tel. Rumah A8. No.Tel. Bimbit
- -
Home Phone No. Mobile Phone No.
A9. Alamat tempat bekerja* _____________________________________________________________________________________________
Workplace Address
_____________________________________________________________________________________________
Gunakan helaian tambahan jika alamat tempat bekerja melebihi daripada satu / Use additional sheets if there is more than one workplace address

A10. No. Kad Pendaftaran Pengenalan Diri * A11. No. Pasport * _______________________
Registration Identity Card No. Passport No.
A12. Tempoh Sah Laku Pasport * Hingga
Validity Period of Passport
Hari Bulan Tahun Until Hari Bulan Tahun
Day Month Year Month Year
Day

A13. No. Permit Kerja / Pas Masuk * ______________________________________ A14. Tarikh Mula Kerja*
Employment Start Date Hari Bulan Tahun
Working Permit / Entry Pass No. Day Month Year

A15. Tempoh Sah Laku Permit Kerja * Hingga

Validity Period of Working Permit / Entry Pass Hari Bulan Tahun Until Hari Bulan Tahun
Day Month Year Day Month Year

A16. Tempoh Kontrak Bekerja * Hingga

Period of Working Contract Until
Hari Bulan Tahun Hari Bulan Tahun
Day Month Year Day Month Year
A17. Masa Bekerja * Hingga
Working Time am / pm am / pm
Until
A18. Kontrak Perkhidmatan * Bertulis Lisan Jika lisan, nyatakan skop kerja : _______________________________________
Service Contract Written Verbal If as verbal, please specify scope af work
_______________________________________________________________________________________________________________________

B. BUTIR-BUTIR MAJIKAN / PARTICULAR OF EMPLOYER

B1. No. Kod Majikan * B2. E-Mel __________________________________ ____ _______
Employer’s Code No. E-mail

B3. Nama Majikan

Employer’s Name

B4. Warganegara* B5. No. Kad Pendaftaran Pengenalan Diri / No. Pasport *
Nationality
________________________ Registration Identity Card No. / Passport No. ________________________

B6. Alamat ________________________________________________________________________________________________

Address
________________________________________________________________________________________________
B7. No. Telefon B8. Hubungan dengan pekerja * ___________________________
Telephone No. -
Relationship with employee

C. BUTIR-BUTIR WARIS / PARTICULAR OF NEXT OF KIN

C1. Nama *
Name

C2. Alamat surat-menyurat * _______________________________________________________________________________________________

Correspondence Address
_______________________________________________________________________________________________
C3. No. Telefon C4. Hubungan dengan pekerja *___________________________
Phone No. -
Relationship with employee

D. PENGESAHAN MAJIKAN / ENDORSEMENT BY EMPLOYER

Saya memperakui bahawa sepanjang pengetahuan dan kepercayaan saya bahawa semua butiran yang dinyatakan adalah benar.
I certify that to the best of my knowledge and belief that all the particulars specified are true.

Tandatangan majikan / wakil majikan yang diberi kuasa : _________________________________________

Signature of Employer / Employer’s authorized representative

Nama Tarikh
Name Date
Tandatangan tidak diperlukan sekiranya borang ini dihantar melalui medium elektronik tertakluk kepada pengesahan oleh PERKESO
Signature is not required if this form is submitted via electronic medium subject to confirmation by SOCSO