Borang 3 (Form 3)

JLKN /P/:03/Pin 2/10

AKTA LATIHAN KHIDMAT NEGARA 2003

(NATIONAL SERVICE TRAINING ACT 2003)
PERATURAN-PERATURAN LATIHAN KHIDMAT NEGARA (PENANGGUHAN TANGGUNGAN) 2004
(NATIONAL SERVICE TRAINING (POSTPONEMENT OF LIABILITY) REGULATIONS 2004)
RAYUAN UNTUK PENANGGUHAN TANGGUNGAN/ RAYUAN UNTUK PERAKUAN PENANGGUHAN
(Peraturan 5)
(APPEAL FOR POSTPONEMENT OF LIABILITY/ APPEAL FOR POSTPONEMENT CERTIFICATE)
(Regulation 5)

1. Nama (Name):

2. No kad pengenalan (NRIC number):

Kegunaan rasmi (Official use)

Diterima oleh (Received by)

:.......................................................................................................

Tarikh diterima (Date received) :.......................................................................................................

Siri (Series)

:............../....................

Kumpulan (Group)

:1

Kod (Code)

:1

Keputusan (Decision)

: Lulus (Approved) / Tidak Lulus (Not Approved)

..............................................
Pengerusi Majlis Latihan Khidmat Negara
(Chairman of National Service Training Council)
/bagi pihak Pengerusi MLKN
(on behalf of NSTC Chairman)

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......................
Tarikh (Date)

3. Butir-butir peribadi (Personal Particulars)

a) Alamat tetap (Permanent address):

Poskod (Postcode):

Bandar (City):

Negeri (State):

b) Alamat surat-menyurat [Jika berbeza daripada di atas] (Postal address [If different from above]):

Poskod (Postcode):

Bandar (City):

Negeri (State):

c) Nombor telefon (Telephone numbers):

Rumah (House):
Bimbit (Handphone):
Lain-lain (Others):
d) Alamat e-mel (E-mail address): .

4. Butir-butir tentang Program Latihan Khidmat Negara (Particulars relating to National Service Training)
a) Nombor rujukan dan tarikh surat pemberitahuan (Reference number and date of notification
letter):
No. Rujukan (Reference No.): .....................................................................................................
Tarikh (Date):

Hari
(Date)

Bulan
(Month)

Tahun
(Year)

b) Tarikh melapor diri untuk latihan: (Date to report for training)

Tarikh (Date):

Hari
(Date)

Bulan
(Month)

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Tahun
(Year)

c) Nama kem untuk latihan (Camp allocated for training):

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

5. Butir-butir rayuan (Particulars of appeal):

a) Nombor rujukan dan tarikh surat penolakan permohonan penangguhan (Reference number and
date of refusal of the application for postponement letter):
No. Rujukan (Reference No.): .....................................................................................................
Tarikh (Date):

Hari
(Date)

Bulan
(Month)

Tahun
(Year)

b) Butir-butir rayuan (Particulars of appeal):

.
c) Senarai dokumen sokongan (List of supporting documents):
i.
ii.
iii.
iv.

d) Nama, alamat dan nombor telefon penyokong (Name, address and telephone numbers of
referees):
Nama (Name)

Alamat (Address)

Rumah (House)

Bimbit (Handphone)

a)

b)

.........................................................................
Tandatangan pemohon (Applicants signature)

..............................
Tarikh (Date)

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