Lampiran B-2

BORANG PERMOHONAN PENGECUALIAN PEMAKAIAN KAEDAH 5 (3) KAEDAH-

KAEDAH KENDERAAN MOTOR (LESEN MEMANDU) 1992

(Sila Gunakan HURUF BESAR CERAIAN apabila mengisi maklumat)

(Please use BLOCK LETTER)

A. BUTIR-BUTIR PERIBADI (PERSONAL PARTICULARS)

1. Nama Pemohon: SMRUTI RANJAN NAYAK

(Name of Applicant)
No. K/P Atau Passport (I/C or Passport No.): P7333097
Sertakan salinan yang disahkan (Attached certified copy)

2. Alamat Tetap Di Malaysia : 07-04-CREST RESIDENCE,JALAN CENDANA,

(Permanent Address in Malaysia) KAMPUNG BARU KUALA LUMPUR
50300
B. KEWARGANEGARAAN : i. Warganegara Malaysia ii. Bukan Warganegara
(Citizenship) (Malaysian) (Non Malaysian)
iii. Pemastautin tetap
Permanent Resident
C. NOMBOR TELEFON : Pejabat : - Rumah : -
Telephone Number Office House

Telefon Bimbit : +60 - 1123736004

Handphone

D. UNTUK BUKAN WARGANEGARA MALAYSIA- Sila Nyatakan Butir-Butir Lanjut Mengenai

(For Non-Malaysian Citizenship) Dokumen Perjalanan Dan Sertakan Salinan
Yang Telah Disahkan.
Please Give Details Of Travelling
Document and Attached A Certified Copy.

1. Negara Asal: INDIA 2. Passport Dikeluarkan Di: KARNATAKA

Country Of Origin Passport Issued At

3. Tempoh Sah Passport: 20/01/2027

Validity of Passport
4. Tujuan Berada Di Malaysia - Sila Kemukakan Dokumen Yang Berkaitan Seperti Permit
Kerja, Pas Tanggungan Dan Lain-Lain.
Purpose Of Staying in Malaysia- Please Attach Relevant Certified Documents a.g. Work
Permit, Dependent Pass etc.
WORK PERMIT

5. Tempoh Berada Di Malaysia: 3 Years 6. Jawatan: MANAGER

Duration Of Stay In Malaysia Designation
7. Nama Syarikat Tempat Bertugas Dan Alamat : STANDARD CHARTERED BANK
Company/Place of Occupation And Address JALAN TEKNOLOGI 8, TAMAN TEKNOLOGI

MALAYSIA, 57000 KUALA LUMPUR,

WILAYAH PERSEKUTUAN KUALA LUMPUR

TARIKH PENERIMAAN: ………………

5. BUTIR-BUTIR LESEN MEMANDU NEGARA LUAR
FOREIGN DOMESTIC DRIVING LICENSE PARTICULARS

a. Lesen Dikeluarkan Oleh : KARNATAKA STATE - INDIAN UNION MOTOR DRIVING LICENCE
License Issued By

b. Tempoh Sah Lesen : 20 YEAR Hingga: 18/01/2037

Validity of License Until

c. Kelas Lesen Memandu : LMV

Classes or Categories of Driving License

6. SILA KEMUKAKAN LESEN MEMANDU YANG DISAHKAN

PLEASE ATTACH CERTIFIED COPY OF DRIVING LICENSE
NOTA: Pemohon Hendaklah Mengemukakan Bukti Telah Memegang Lesen Memandu Bagi Tempoh Melebihi 2 Tahun.
Sekiranya Tidak Dapat Menunjukkan Bukti, Lesen Yang Diluluskan Adalah Lesen Percubaan Sahaja. Pemegang
Lesen Percubaan adalah TIDAK LAYAK untuk memohon Permit Memandu Antarabangsa ( IDP ).

NOTE: Applicant Is Required To Submit Proof Of Holding Such Driving License For A Duration Exceeding 2 years.
(Current, Previous Driving License Or A Certification Of License Particulars From The Licensing Authority
Concerned). If Not, Approval Will Be Given For A 'Probationary' License. The Probationary Licensee Is NOT
QUALIFIED To Apply For International Driving Permit ( IDP ).

7. BUTIR-BUTIR LESEN MEMANDU MALAYSIA (JIKA ADA)

MALAYSIAN DOMESTIC DRIVING LICENSE PARTICULARS - IF ANY

a. No. Siri Lesen : 2. Kelas Lesen Memandu :

License Serial No. Driving License Class

3. Tempoh Sah Lesen : Hingga

Validity Of License Until

8. JUSTIFIKASI UNTUK PERMOHONAN (JUSTIFICATION FOR APPLICATION)

RESPECTED SIR,

I AM SMRUTI RANJAN NAYAK AND I WORK IN STANDARD CHARTERED BANK. ME AND MY WIFE BOTH WORK IN KL

IT IS NOW 3 YEARS AND WE HAVE DECIDED TO HAVE A FAMILY IN MALAYSIA. MY WIFE IS NOW 6 MONTHS PREGNENT

DURING EMERGENCY I CAN DRIVE TO HOSPITAL FOR CHECK UP;HENCE REQUESTING FOR MALAYSIAN DRIVING LICENSE

Tandatangan Pemohon Tarikh Memohon

Applicant's Signature Date Of Application
Sila Kemukakan Permohonan Kepada:
Please Forward Application To

IBU PEJABAT,
JABATAN PENGANGKUTAN JALAN MALAYSIA
BAHAGIAN PELESENAN PEMANDU
ARAS 4, NO. 26 JALAN TUN HUSSEIN, PERSIARAN PERDANA, PRESINT 4
PUSAT PENTADBIRAN KERAJAAN PERSEKUTUAN
62620 PUTRAJAYA
TEL: 03-80008000
FAX: 03-88811097