BAHAGIAN PERKAHWINAN DAN PEMBANGUNAN KELUARGA

JABATAN AGAMA ISLAM WILAYAH PERSEKUTUAN

KOMPLEKS PUSAT ISLAM, ARAS 7, BLOK E2 , KOMPLEKS E, TINGKAT 8, BLOK 4,UJANA KEWANGAN,
JALAN PERDANA, PUSAT PENTADBIRAN KERAJAAN PETI SURAT 82197,
50676 KUALA LUMPUR PERSEKUTUAN, 87209 WILAYAH PERSEKUTUAN
Tel: 03-2274 9333 62502 PUTRAJAYA LABUAN
Tel: 087 415 311
Faks: 087 417 595

BORANG PERMOHONAN
KURSUS PRA PERKAHWINAN ISLAM

TARIKH KURSUS : ...............................................................................................................................

KURSUS KAHWIN DANAU KOTA
TEMPAT KURSUS : ...............................................................................................................................

MAKLUMAT PESERTA (Potong * mana yang tidak berkaitan)

1. Nama Penuh : ..............................................................................................................................................................................................

2. No. Kad Pengenalan : ......................................................................... 3. Jantina : ....................................................................................

4. No. Kad Pengenalan Tentera : ........................................................... 5. Tarikh Lahir : .............................................................................

6. No. Kad Pengenalan Polis : ................................................................ 7. Tempat Lahir : ..........................................................................

8. No. Passport : ..................................................................................... 9. Bangsa : ....................................................................................

10. Warganegara : ................................................................................... 11.Negara Asal : ............................................................................

12. Status diri: Bujang / Berkahwin / Duda / Janda / Bertunang

13. Pendidikan Tertinggi : .................................................................................................................................................................................

14. Tarikh Masuk Islam (Jika berkaitan) : .........................................................................................................................................................

15. Alamat Rumah : ...........................................................................................................................................................................................

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16. No Tel : ........................................................................................................................................................................................................

17. No Whatsapp : ............................................................................................................................................................................................

18. E-mel : .........................................................................................................................................................................................................

MAKLUMAT PEKERJAAN

1. Jenis Pekerjaan: *Kerajaan/Swasta/Badan Berkanun/GLC/Sendiri/Pesara/Pelajar/Tidak Bekerja

2. Pekerjaan : ................................................................................... 3. Pendapatan (RM) : ...................................................................

4. Alamat Tempat Bekerja : ..............................................................................................................................................................................

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

5. No. Telefon : ...............................................................................

Tandatangan Pemohon Untuk kegunaan kursus kahwin

.............................................. Permohonan ini diluluskan / tidak diluluskan

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

No. Kad Pengenalan : ..............................................................

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Tandatangan Pengurus Syarikat
Nama :
Jawatan :