Borang 1 (Form 1) JLKN /P/:01/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) PERMOHONAN BAGIPERAKUAN PENANGGUHAN (Peraturan 3) (APPLICATION FOR POSTPONEMENT OF LIABILITY/ POSTPONEMENT CERTIFICATE) (Regulation 3) *(Sila baca arahan di muka surat 5 dan 6sebelum mengisi borang ini) (Please read the instructions on page 5 and 6before filling up this form)

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 2 3

Kod (Code)

:1

2

3

Keputusan(Decision)

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

.............................................. Ketua Pengarah (Director General) /bagi pihak Ketua Pengarah (on behalf of Director General)

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

1/6

......... Rujukan(Reference No.... Butir-butir peribadi(Personal Particulars) a) Alamat tetap(Permanent address): Poskod(Postcode): Negeri(State): Bandar (City): b) Alamatsurat-menyurat [Jika berbeza daripada di atas] (Postal address [If different from above]): Poskod(Postcode): Negeri(State): Bandar (City): c) Nombor telefon(Telephone numbers): Rumah (House): Bimbit (Handphone): Lain-lain (Others): d) Alamat e-mel(E-mail address): …………………………………………………………………………......3.. 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....... 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) Tahun (Year) 2/6 ................................... 4............................): ................

...... (Currently studying In Form Lower 6/Upper 6 and will be sitting for STPM examination this year/ next year........ 3/6 .......................... Others..................... Silatandakan( X ) di mana berkenaan dan kepilkan bersama dokumen sokongan yang berkaitan.........) Berada di Tingkatan Enam Bawah/Atas dan akan mengambil peperiksaan STPM pada tahun ini/ tahun hadapan....) Lain-lain. (Please specify) : ....................... Please mark ( X ) where appropriate and attach all relevant supporting documents.... (Please specify) : ........................... (Currently studying in Form Five and will be sitting for SPM examination this year..... (Sila nyatakan) : ……………………………………………………………………………........... Butir-butir sebab memohon penangguhan....................................................................................................................................................... (Please specify) : ... c) Keadaan yang akan menimbulkan kesusahan luar biasa(Circumstances that will give rise to exceptional hardships) Sedang hamil (Currently pregnant) Tarikh dijangka bersalin (Expected date of giving birth) : Hari : (Date) Bulan (Month) Tahun (Year) Lain-lain..........c) Nama kem untuk latihan(Camp allocated for training): ........ b) Sedang meneruskan pengajian (Currently pursuing studies) Sedang meneruskan pengajian di mana-mana institusi pengajian tinggi (Pursuing studies inany higher educational institutions) Tarikh mula belajar (Date of commence) Tarikh dijangka tamat belajar (Expected date of completion) : Hari : (Date) : Hari : (Date) Bulan (Month) Bulan (Month) Tahun (Year) Tahun (Year) Lain-lain............................................................... (Silanyatakan) : ……………………………………………………………………………................. (Particulars on the reason that cause for postponement.............................. (Sila nyatakan) : ……………………………………………………………………………......) a) Akan menduduki peperiksaan utama (Will be sitting for a major examination) Masihberada di Tingkatan Lima dan akan mengambil peperiksaan SPM pada tahun ini.................... Others.... Others.. 5........................

................ Tandatangan pemohon(Applicant’s signature) ........ address and telephone numbers of referees) Nama (Name) a) Alamat (Address) Rumah (House) Bimbit (Handphone) b) ... Tarikh(Date) 4/6 ......... alamat dan nombor telefon penyokong (Name......................6.......................... Nama.................. Senarai dokumen sokongan (List of supporting documents) a) b) c) d) ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… 7......

Penggawa. Jaksa Pendamai.3.1. ditandatangani dan dilampirkan dengan dokumen yang lengkap iaitu: 3.1. Apa-apa keadaan yang akan menimbulkan kesusahan luar biasa 3. ATAU Surat pengesahan rasmi daripada Lembaga Peperiksaan Malaysia.1.1. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. Bagi memastikan pemprosesan segera permohonan tuan / puan. Sekiranya permohonan pihak tuan / puan anda ditolak.2.1. Salinan dokumen sokongan yang berkaitan. DAN Salinan resit pembayaran yuran pengajian (TERKINI) yang telah dibayar (sekurang-kurangnya ½ daripada jumlah yuran sebenar).2. Tok Sidang. Bagi yang akan menduduki peperiksaan utama 3. Institusi Pengajian Tinggi Awam (IPTA) 3. Untuk meluluskan permohonan anda.2. 3.2.2. Lain-lain kesusahan luar biasa 3. Untuk makluman lanjut.3. Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi. 3. 3. 3.2.1. DAN 3. 2. sila hubungi:Jabatan Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5.2. 4. ATAU Surat rasmi mengesahkan bahawa pemohon sedang menghadiri kursus (sila nyatakan tempoh pengajian) daripada institusi pengajian tinggi.2. Bangunan Zetro Jalan 9/27C.2.2. ATAU 3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5/6 . 3. Sedang hamil 3.1. Bagi yang sedang meneruskan pengajian 3. Komandan atau Pengetua Sekolah.2.1.2.2. tepat dan mudah dibaca. 3.2. Permohonan yang mengandungi maklumat yang tidak tepat atau tidak boleh dibaca tidak akan dilayan. sila pastikan Borang ini diisi dengan lengkap. Majistret. ATAU Salinan surat tawaran biasiswa.1. sila pastikan butir-butir adalah diisi dengan betul. Institusi Pengajian Tinggi Swasta (IPTS) 3.1.2.3.3. Bangunan Zetro Jalan 9/27C. Surat Sokongan yang jelas menyatakan kesusahan yang dialami oleh pelatih daripada Pesuruhjaya Sumpah. Semua permohonan bagi perakuan penangguhan hendaklah dibuat dalam masa sepuluh (10) hari selepas penyiaran perintah Menteri yang menghendaki peserta menjalani Latihan Khidmat Negara atau dalam tempoh masa yang dipanjangkan sebagaimana yang boleh dibenarkan oleh pihak berkuasa yang sepatutnya. Isi borang dengan HANYAmenggunakan huruf besar dan pen mata bola. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian. 3. Salinan surat tawaran belajar daripada institusi pengajian tinggi yang dinyatakan tempoh pengajian.1.2. 3. 3.2. Surat pengesahan rasmi daripada doktor. anda boleh membuat rayuan kepada Majlis Latihan Khidmat Negara dengan menggunakan Borang 3 (JLKN/P/:03/Pin2/10).2.3.Arahan untuk Borang 1 (JLKN /P/:01/Pin 2/10) 1.2.1.4.2.1.3.2.3. Surat pengesahan rasmi daripada pihak sekolah. Penghulu. Rayuan itu bolehlah dialamatkan kepada:Majlis Latihan Khidmat Negara Kementerian Pertahanan Malaysia Aras 2-5.

3. please make sure that all details filled up are correct.2. Bangunan Zetro Jalan 9/27C.1.2 A copy of the Letter of Offer stating the duration of the course by the current Higher Educational Institution that the applicant is attending.1.2.1 A formal confirmation letter from a doctor Other exceptional hardship 3.1.2. For those who are pursuing studies 3.2 3.1 A formal appeal letter certified by a Commissioner for Oath.2. an appeal shall lie to the National Service Training Council by using form JLKN/P/:03/PIN 2/10.1 3.3. signed by the applicant and enclosed with all the required documents: 3. OR A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.1 For those that will be sitting for a major examination 3. If your application is rejected. Justice of Peace. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 5. To ensure prompt process of your application. 3.2 Higher Educational Institution (Private) 3. AND A copy of the receipt (LATEST) proving payment of fees to the current Higher Educational Institution that the applicant is attending. OR A formal letter from the Examination Council of Malaysia 2.2. Tok Sidang. AND 3. Kindly fill up this application form using ONLY block letters and ball point pen.2.2.2 A formal letter from the current school.2. To expedite this application. Commandant or School Principal certifying that the applicant is undergoing that particular hardship.2 3. OR 3.3.3 A copy of the Letter of Offer stating the duration of the course by the current Higher Educational Institution that the applicant is attending. The National Service Training Department reserves the right to reject application that is incomplete.2.1. please make sure that this form is filled upcompletely.1 3.1 3.3. Seksyen 5 Wangsa Maju 53300 Kuala Lumpur 6/6 .2. Penggawa.3.4 A formal letter certifying that the applicant is attending the course (state the course duration) by the current Higher Educational Institution.2 4.2. Bangunan Zetro Jalan 9/27C.2.2. 3. The appeal shall be addressed to :National Service Training Council Ministry of Defence Malaysia Aras 2-5.2. For further enquiries.1 Currently pregnant 3. please contact :National Service Training Department Ministry of Defence Malaysia Aras 2-5.3 Any other circumstances that will give rise to exceptional hardship 3. Magistrate. OR A copy of the Scholarship Offer Letter proving that the course that the applicant is attending will be sponsored by a third party. accurate and legible. 3.Instructions for Form 1 (JLKN/P/:01/Pin 2/10) 1. All applications for a postponement certificate must be made within ten (10) days after the publication of the order of the Minister requiring participants to undergo national service training or within such extended time as the proper authority may allow. 3. Penghulu.2 A copy of any supporting documents proving that the applicant is undergoing that particular hardship.1 Higher Educational Institution (Public) 3.1.