No.

Borang : JAKIM B-14

No. Pindaan : 0

DARUL QURAN
JABATAN KEMAJUAN ISLAM MALAYSIA
(JAKIM)
Gambar Berukuran
Pasport

BORANG PERMOHONAN
PROGRAM DIPLOMA TAHFIZ AL-QURAN DAN
AL-QIRAAT SESI 2023-2026
PERHATIAN :
i. Sila baca dengan teliti sebelum mengisi borang.
ii. Borang hendaklah diisikan dalam HURUF BESAR
iii. Borang permohonan yang telah lengkap diisi hendaklah cetak dan dibawa
semasa menghadiri temuduga.

ATTENTION :
i. Please read carefully before completing the form.
ii. The form must be filled in CAPITAL LETTERS
iii. The complete application form must be printed out and taken during interview.

A. MAKLUMAT PEMOHON (PERSONAL PARTICULARS)

1. Nama Penuh (mengikut K.P) :

............................................................................................................................
Full Name (According to your IC)

2. Email :
...........................................................................................................................
Email Address

3. Alamat Surat-menyurat : ...........................................................................................................................

Mailing Address
...........................................................................................................................

4. No. Telefon : 5. Jantina :

..................................... ..........................................
Phone Number Gender

6. No. K/P :
..............................................................................
I/C Number

7. Tarikh Lahir : 8. Negeri Kelahiran :

..................................... ..........................................
Date of Birth State of Birth

9. Keturunan :
..........................................................................................................................
Race

10. Kewarganegaraan : 11. Ukuran Baju :

.....................................
Nationality Dress Size ...........................

B. PUSAT TEMUDUGA (CENTER OF INTERVIEW)

12. Pilih Pusat Temuduga : ............................................................................

UNTUK KEGUNAAN PEJABAT (OFFICE USE)

No. Rujukan (Reference Number): Tarikh Terima (Date Receive):
Panggilan Temuduga (Interview): Layak (Yes) / Tidak (No) Catatan :
C. KELULUSAN AKADEMIK (Sertakan salinan sijil yang disahkan)
ACADEMIC QUALIFICATION ()(Please bring original and copy of certification on interview)

13. Nama Sekolah Terakhir: Name of last school

...............................................................................................
attended :

14. Alamat Sekolah Terakhir : Address of the last school

...............................................................................................
attended :

15. Tahun Peperiksaan : ..........................................

- Keputusan Sijil Pelajaran Malaysia (SPM) atau Sila tandakan { √ } pada

keputusan peperiksaan
- Percubaan SPM (calon SPM 2022); atau
yang tertinggi
- Keputusan Peperiksaan Tingkatan 5 (calon SPM 2022)

16. Mata Pelajaran :

Mata Pelajaran (Subject) Gred (Grade)
Mata Pelajaran (Subject) Gred (Grade)
Al-Syariah
Bahasa Melayu / (Malay
Language) Turath Dirasat Islamiah
Bahasa Inggeris / (English)
Manahij al-Ulum al-Islamiah
Pendidikan al-Quran & al-Sunnah
Maharat al-Quran
Pendidikan Syariah Islam
Manahij Ulum al-Islamiyah
Pendidikan Islam
Bahasa Arab
Tasawwur Islam
Al-Adab wa al-Balaghah
Usuluddin
Al-Lughah al-Arabiah al-Mu’asirah
Turath al-Quran dan Sunnah
Turath Bahasa Arab

20. Mata Pelajaran (Subjects):

SIJIL-SIJIL LAIN YANG SETARAF DENGAN SPM
Mata Pelajaran (subject) Gred (Grade)
17. Sila Nyatakan :
Please state ...........................................................

18. Tahun Peperiksaan :

(Year of Exemination) ...................................................

19. Nama Peperiksaan :

Exemination Name ....................................................
D. MAKLUMAT AKADEMIK PELAJAR (STUDENT ACADEMIC INFORMATION)

21. Maklumat Pendidikan Menengah (Secondary education information) :

Tahun Tamat (Year Keputusan

Bil Nama Sekolah (School Name)
End) Tertinggi (Highest Result)

1.

2.

22. Aktiviti Persatuan/Kelab Dalaman dan Luar Sekolah di Peringkat Menengah :

Assocation activity/Indoor and Outdoor club at the secendory level

Bil Tahun (Year) Persatuan (Assocation/Club) Jawatan (Position)

1.

2.

3.

4.

23. Sekiranya anda pernah menyertai tilawah Al-Quran atau majlis Hafazan, sila nyatakan :
Have you competed in any Al-Quran recital or memorization competition? Please state :

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

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

24. Cita-cita dibidang akademik :

Academic ambition. (Please indicate)

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

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

25. Sebab utama memilih Program Diploma Tahfiz al-Quran dan al-Qiraat Darul Quran JAKIM :
The main reason for choosing The Programme Of Diploma Of Tahfiz al-Quran and al-Qiraat Darul Quran JAKIM:

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

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

26. Kursus-kursus yang pernah dihadiri dalam tempoh 2 tahun lepas :

Courses that you have attended in the last two years :

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

..............................................................................................................................................................................................
E. MAKLUMAT IBU / BAPA / PENJAGA
MOTHER / FATHER / GUARDIAN INFORMATION

27. Nama : Name .............................................................................................................................................

28. Alamat Surat-menyurat : .............................................................................................................................................

Mailing Address
.............................................................................................................................................

29. Poskod : Postcode ...........................................

30. No. Telefon : 31. No. Kad Pengenalan :

........................................... ...........................................
Phone Number IC Number

32. Pertalian Hubungan :

...........................................
Relationship

33. Pekerjaan : Occupation ...........................................................................................

34. Pendapatan Bulanan

Ibu/Bapa/Penjaga :
RM ............................................
Monthly Income
(Mother/Father/Guardian)

35. Tanggungan Ibu/Bapa/Penjaga :

Dependants of Mother/Father/Guardian

Umur
Bil Nama Anak/Tanggungan / (Name) Sekolah/Institusi / (School/Institution)
/ (Age)
1.
2.
3.
4.

F. PERAKUAN PEMOHON / VERIFICATION OF INFORMATION

Saya mengaku bahawa keterangan yang diberikan di atas adalah benar. Saya akui bahawa pihak Darul Quran berhak
menolak permohonan ini sekiranya mana-mana keterangan atau salinan-salinan sijil yang dikemukakan adalah tidak
benar.
I declare that the information given above is true. I agree that the Darul Quran reserves the right to reject this
application if any of the information or copies of the certificates submitted is invalid.

Tandatangan Pemohon : ................................................ Tarikh: ............................

Appicant Signature Date

G. PENGESAHAN PERMOHONAN (VERIFICATION OF APPLICATION)

(Pengesahan ini perlu ditandatangani oleh Pegawai Kumpulan Pengurusan & Profesional / Pengetua Sekolah /
Pengerusi JKKK)
(This verification must be signed by an officer of yhe Professional and Management / School Principal / JKK
Chairman)

Saya telah menyemak semua dokumen dan dengan ini mengesahkan semua maklumat yang dinyatakan di atas serta
sijil dan surat perakuan yang disertakan adalah benar.
I have checked all documents and hereby certify that all the information stated above as well as certificate and letter of
declerations attached is true.

Nama dan Cop Jabatan Name and Department Stamp:

Tandatangan : ................................................ Tarikh: ...........................

Signature Date
 DARUL QURAN
JABATAN KEMAJUAN ISLAM MALAYSIA

BORANG PERAKUAN DIRI

A. MAKLUMAT PERAKUAN KESIHATAN (HEALTH CERTIFIED INFORMATION)

Nama Penuh :
Full Name
No. K/P :
IC Number
Nama Sekolah :
Name of last school attended :
Alamat Sekolah Terakhir :
Address of the last school
attended :

1. Pernahkan anda mengidap penyakit seperti berikut :

Has your diagnosis as follows
Alahan / Lelah Ya (Yes) Tidak (No)
a.
Allergy/Asthma
Jantung
b.
Heart Attack
Tibi / Kusta
c.
Tuberculosis / Leprosy
Sakit Jiwa
d.
Mental Ilness
Migrain
e.
Migraine
Lain-lain
f.
Others
2. Pernahkan anda (Hane you ever) :
Dimasukkan ke wad : Tidak (No)
a. Ya(Yes)
Warded in hospital
Menjalani Pembedahan :
b.
Having a surgery
Menjalani Rawatan Psikiatri :
c.
Undergone Psychiatric treatment

B. MAKLUMAT PERAKUAN AKHLAK

1. Pernahkan anda : (Have you ever)

Merokok Ya(Yes) Tidak (No)
a.
Smoking
Ponteng Kelas / Sekolah
b.
Truancy
Terlibat dengan Salah Laku
c.
Involved with misconduct

Saya mengaku perakuan di atas adalah benar

I declared the above statements is true.

( T/Tangan Pemohon ) ( T/Tangan Ibu/Bapa/Penjaga )

Application signature Mother/Father/Guardian Signature