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 : Crest Residence,Jalan Cendana, Kampung Baru

(Permanent Address in Malaysia) 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: India

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
Manager
5. Tempoh Berada Di Malaysia: 6. Jawatan:
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 Years 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. It has been
3 years with my family. I travel to Office daily for my work and to take my family

outside in weekends hence would request for Malaysian Driving Licence

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