JABATAN PEMBANGUNAN KEMAHIRAN

KEMENTERIAN SUMBER MANUSIA, MALAYSIA

Penerimaan Permohonan Pengambilan Ke Dalam Pusat Yang Ditauliah Oleh JPK
Acknowledgement Of Application For Intake Into Centre Accredited By JPK
No. Ruj. Permohonan : CENT0108907 Tarikh Mohon : 03 Nov 2009
Application Reference No. Date Applied
Mohon Untuk : / Sendiri Bagi Pihak Calon
Apply For Own Self On-Behalf Of A Candidate

Perlu Bantuan Kewangan? : / Tidak Perlu Perlu

Require Financial Assistance? Not Required Required

Jenis Kursus Kemahiran : / Sijil Kemahiran Malaysia (SKM)

Type Of Skills Course Malaysian Skills Certificate (MSC)

Bahagian A - Daftar Oleh (perlu diisi, jika pendaftaran adalah bagi pihak calon)
Part A - Register By (Required to filled, if registration is on-behalf of a candidate)
No. K/P Baru / ID Lain / Passport : _____________________ Warganegara : Malaysia Lain-lain
New NRIC / Other Id. / Passport No. Nationality Malaysian Others

Nama :
Name
Hubungan Dengan Calon : Ibu-Bapa Abang / Kakak / Adik Penjaga Suami / Isteri
Relationship With The Candidate Parent Sibling Guardian Spouse

Majikan(nyatakan Nama Syarikat) ___________________________________

Employer(specify Company Name)

Pusat Bertauliah (nyatakan Nama _________________________________________

Pusat)
Accredited Center(specify Center
Name)

Lain-lain, nyatakan _______________________________________________

Others,specify

No. Telefon : _____________________________ No. Bimbit : ________________________

Telephone No. Handphone No.
Alamat e-Mel : ______________________________________________________________________________
e-Mail Address
Bahagian B - Maklumat Peribadi Calon (Pelajar)
Part B - Candidate's (Trainee's) Particulars
No. K/P Baru / ID Lain / Pasport : 850622075113 Warganegara : / Malaysia Lain-lain
New NRIC / Other Id. / Passport No. Nationality Malaysian Others

Nama : Muhamad Nabil Bin Mansor Tarikh Lahir : 22 Jun 1985

Name Date Of Birth
Jantina : / Lelaki Perempuan Taraf Perkahwinan : / Belum Kahwin Sudah Kahwin
Gender Male Female Marital Status Not Married Married

Bangsa : / Melayu Cina India Lain-lain,nyatakan : _____________________

Race Malay Chinese Indian Others, please specify

Bumiputera : / Ya Tidak
Bumiputera
Kategori : Lepasan Sekolah Menengah Lepasan Graduan / Bekerja Tiada Pekerjaan Pelajar
Category Secondary School Leaver Fresh Graduate Employed Unemployed Student

Alamat Kediaman / Residential Address Alamat Surat-Menyurat / Correspondence Address

10483 Permatang Tok Jaya 10483 Permatang Tok Jaya
Sungai Dua Sungai Dua
13800 Butterworth 13800 Butterworth
PULAU PINANG PULAU PINANG
MALAYSIA MALAYSIA

No. Telefon : 043562639 No. Bimbit : 0134549958

Telephone No. Handphone No.
Alamat e-Mel : nabil-penangbridge@yahoo.com.my
e-Mail Address

Bahagian C - Maklumat Keputusan Akademik Tertinggi (Wajib)

Part C - Highest Academic Results (Compulsory)

Kelulusan Akademik Tertinggi / Highest Academic Level

Tamat Sekolah Rendah SPMV (Sekolah Vokasional)

Primary School Leaver Vocational School Leaver

SRP / PMR (Tingkatan 3) STPM

Lower Secondary Leaver (Form 3) Higher Education Leaver

MCE / SPM (Tingkatan 5) / Lain-lain (nyatakan): Ijazah Sarjana Muda Elektrik-

Higher Secondary Leaver (Form 5) Others (specify) Mekatronik

Tahun Nama Sekolah / Institut Grad / Agregat

Year Name Of School / Institute Grade / Aggregate
2008 Universiti Teknologi Malaysia 3.33

Mata Pelajaran Keputusan

Syllabus Results
BAHASA MALAYSIA A2
BAHASA INGGERIS / ENGLISH C5
MATEMATIK / MATHEMATICS A1
SAINS / SCIENCE -
SEJARAH / HISTORY B4

Bahagian D - Maklumat Kelayakan Sijil Kemahiran (jika ada)

Part D - Information Of Skills Certificate Qualifications (if any)
Jenis Sijil Tahun No. Siri Sijil Kod Program Nama Program Institusi Latihan
Type Of Cert. Year Cert's Serial No. Programme Code Programme Name Training Institution
Bahagian E - Program Kemahiran & Pusat Bertauliah Pilihan Saya (Maksima :2 Program)
Part E -My Choice Of Skills Programme & Accredited Centre (Maximum : 2 Programmes)
Jenis Program Kod Program Nama Program Tahap
Type Of Programme Code Programme Name Level
Programme
SKM E-011-2 JURUTEKNIK ELEKTRONIK INDUSTRI - PERALATAN 2

Kod Pusat Nama & Alamat Pusat No. Pengambilan Pengambilan Sila Daftar Pada / Sebelum
Centre Code Centre Name & Address Intake No. Intake Please Enroll On / Before
K01001 INSTITUT LATIHAN K01001-E-011-2- SESI PENGAMBILAN PPT-KHAS 10 Nov 2009
PERINDUSTRIAN 0143
Jalan Kuchai Lama
No. Telefon Tempoh Latihan Jenis Yuran / Program (RM)
58200 Kuala Lumpur
KL MALAYSIA Telephone No. Training Duration Type Fees/Programme (RM)
03-79817495 09 Nov 2009 - 15 May Sambilan 0.00
2010
Keputusan / Komen Penilaian (jika ada):
Assessment Result / Comment (if any)

Jenis Program Kod Program Nama Program Tahap

Type Of Programme Code Programme Name Level
Programme
SKM E-011-3 JURUTEKNIK KANAN ELEKTRONIK INDUSTRI - PERALATAN 3

Kod Pusat Nama & Alamat Pusat No. Pengambilan Pengambilan Sila Daftar Pada / Sebelum
Centre Code Centre Name & Address Intake No. Intake Please Enroll On / Before
K01001 INSTITUT LATIHAN K01001-E-011-3- sesi pengambilan ppt-khas 10 Nov 2009
PERINDUSTRIAN 0145
Jalan Kuchai Lama No. Telefon Tempoh Latihan Jenis Yuran / Program (RM)
58200 Kuala Lumpur
KL MALAYSIA Telephone No. Training Duration Type Fees/Programme (RM)
03-79817495 09 Nov 2009 - 09 Nov Sambilan 0.00
2010
Keputusan / Komen Penilaian (jika ada):
Assessment Result / Comment (if any)

Untuk memastikan permohonan kursus tidak diambil oleh calon lain, anda hendaklah mendaftar dengan pusat berkenaan

NOTIS PADA tarikh yang tertera di Bahagian E. Jika gagal berbuat demikian, permohonan ini akan DITOLAK
PENTING
Sila ambil perhatian bahawa, permohonan ini TIDAK MENJAMIN tempat untuk anda di pusat berkenaan. Anda hendaklah
menduduki dan lulus dalam penilaian keperluan pra-masuk yang dijalankan oleh pusat berkenaan sebelum pendaftaran
IMPORTANT
NOTICE pengambilan dilakukan.

To ensure your reserved seat is not taken up by others, please ensure that you enroll with the respective centre
on the date stipulated on Part E. Fail to do so will result in this application being REJECTED.

Please take note that, this application does NOT GUARANTEE you for a seat with the respective centre. You have
to sit & pass the pre-requisite entry requirement conducted and assessed by the respective centre prior the enrollment.

Bahagian F - Pengakuan
Part F - Declaration
Saya mengaku bahawa maklumat yang saya beri di dalam borang permohonan ini adalah benar. Saya memahami bahawa sekiranya
ada di antara maklumat ini didapati palsu, permohonan saya akan dibatalkan.

I hereby declared that all information provided by me are true. I understand that if the information are false, my application will be cancelled.