Borang_Rayuan_Penangguhan_Borang_3 by IsmailAli100

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									                                                                                                                                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                       2                         3


  Kod (Code)                                   :1                       2                         3


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


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




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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                Bulan                  Tahun
                                              (Date)               (Month)                (Year)

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

          Tarikh (Date):                       Hari                Bulan                  Tahun
                                              (Date)               (Month)                (Year)


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     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                   Bulan                      Tahun
                                                       (Date)                  (Month)                    (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 (Applicant’s signature)                                                                                          Tarikh (Date)




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