Kursus yang ditawarkan : Pegawai Keselamatan dan

Kesihatan (SHO)

•Tarikh : 01-30/11/2016

•Tempoh : 22 hari

•Yuran kursus : Pembiayaan sepenuhnya oleh1 MALAYSIAGRIP*

•Syarat kelayakan

•< 2000 - SPM Gred 3 atau

•> 2000 - Minimum SPM kredit6C B.Melayu, B.Inggeris, Matematik Lulus 8E Sains dan 2 Matapelajaran lain atau

•Diploma keatas dan

•Majikan perlu berdaftar dengan PSMB dan

•Pekerja perlu mendapatkan kelulusanmajikan

•Kumpulan sasaran

•Pekerja warganegara Malaysia yang ingin meningkatkan taraf pendidikan

•Mempunyai pengalaman dalam pengurusan Projek

•Permohonan adalah berpandukankelulusan dari pihak PSMB

1 MALAYSIA GLOBALLY RECOGNISED INDUSTRY AND

PROPFESIONAL CERTIFICATION

(1 MALAYSIAGRIP)

Permohonan kursusNIOSH dan PSMB

•Borang yang dilampirkan perludiisi dan diserahkan

Semakan Kelulusan PSMB

•Pihak NIOSH akan membuat semakan untuk kelayakan

Menghadiri kursus

•Menghadiri kursus22 hari setelahmendapatkelulusan

Pendaftaran Peperiksaan SHO

•Mendaftar peperiksaan setelah tamat kursus

Bengkel

•Perlu menghadiri Kursus bengkel sebelum peperiksaan

Menduduki peperiksaan

•Perlu menjawab 4 kertas ujian

Sebarang Pertanyaan boleh menghubungi kami di:

Tel : 03 – 8911 3973/3974

Email :ercd.niosh@gmail.com

Website : www.niosh.com.my

Dokumen yang

diperlukan

Salinan Mykad,

salinan slip gaji

terkini, dan salinan

sijil akademikNIOSH PSMB

INSTITUT KESELAMATAN DAN KESIHATAN PEKERJAAN NEGARANATIONAL INSTITUTE OF OCCUPATIONAL SAFETY AND HEALTH (243042-U)

BORANG PERMOHONAN KURSUSCOURSE APPLICATION FORM

TEL : 03 - 8911 3800 FAX : 03 - 8926 3900 URL : www.niosh.com.my

NIOSH-A46P31-T Rev 6

TAJUK KURSUS COURSE TITLE TARIKH KURSUS COURSE DATE

A. MAKLUMAT PEMOHON APPLICANT’S INFORMATION

B. MAKLUMAT PENAJAAN SPONSOR’S INFORMATION

NAMA NAME

NAMA DI ATAS KADHOLDER NAME

MYKAD/ PASPORTMYKAD/ PASSPORT

ALAMAT SURAT-MENYURATMAILING ADDRESS

JANTINA GENDER

BANDARCITY

PEREMPUANFEMALE

LELAKIMALE

KELAYAKAN TERTINGGIHIGHEST QUALIFICATION

SPM/ MCE SPMV DIPLOMA

IJAZAH SARJANA MASTER’S DEGREE

DOKTOR FALSAFAH (PhD)DOCTOR of PHILOSOPHY (PhD)

IJAZAH SARJANA MUDABACHELOR’S DEGREE

UMURAGE

NAMA NAME

LAIN-LAIN, NYATAKANOTHERS, PLEASE SPECIFY

TAJAAN SENDIRISELF-SPONSORED

TAJAAN SYARIKATCOMPANY SPONSOREDPENAJA SPONSOR

BIDANG PENGAJIANFIELD OF STUDY

IMMEDIATE FAMILYWARIS TERDEKAT

EMERGENCY CONTACT NO.NO UNTUK DIHUBUNGI

RELATIONHUBUNGAN

E-MELE-MAIL

JAWATAN SEMASACURRENT POSITION

POSKODPOSTCODE

NEGERISTATE

ALAMAT SURAT-MENYURATMAILING ADDRESS

BANDARCITY

POSKODPOSTCODE

NEGERISTATE

NO. TELEFON TELEPHONE NO.

NO. FAKSIMILI FACSIMILE NO.

NO. TEL. BIMBIT HANDPHONE NO.

NO. TELEFON TELEPHONE NO.

PEGAWAI BERTUGASPERSON IN-CHARGE

JAWATANDESIGNATION

TARIKH LAHIRDATE of BIRTH

JENIS INDUSTRI (PILIH SALAH SATU)TYPE OF INDUSTRY (TICK ONE)

PEMBUATANMANUFACTURING

PERLOMBONGAN & KUARIMINING & QUARRYING

C. MAKLUMAT KEAHLIAN MEMBERSHIP INFORMATION

D. MAKLUMAT PEMBAYARAN PAYMENT INFORMATION

D. PENTING IMPORTANT

SILA HANTARKAN BORANG PERMOHONAN YANG TELAH LENGKAP KEPADA :PLEASE SEND COMPLETE APPLICATION FORM TO :

KEAHLIAN NIOSHNIOSH MEMBERSHIP

NO. KEAHLIANMEMBERSHIP NO.

YAYES

TIDAKNO

PERSEORANGANINDIVIDUAL

JIKA YAIF YES

KORPORATCORPORATE

KAEDAH PEMBAYARANPAYMENT METHOD

TUNAICASH

KIRIMAN WANGMONEY ORDER

DRAF BANKBANK DRAFT

PESANAN KERAJAAN (LO)LOCAL ORDER (LO)

BAYARAN SECARA ONLINE (MAYBANK2U)ONLINE PAYMENT (MAYBANK2U)

KAD KREDITCREDIT CARD

CEKCHEQUE

TANDATANGANPEMOHONAPPLICANT’S SIGNATURE

HARGA KURSUSCOURSE FEE

PERKHIDMATAN AWAM & PENGUATKUASAANPUBLIC SERVICE & AUTHORITY

PEMBINAANCONSTRUCTION

PEMBORONG & PERUNCITANWHOLESALE & RETAIL TRADE

HOTEL & RESTORANHOTEL & RESTAURANT

PERTANIAN, PERHUTANAN & PERIKANANAGRICULTURE, FORESTRY & AQUACULTURE

KEWANGAN, INSURAN, HARTANAH & PERKHIDMATAN PERNIAGAANFINANCE, INSURANCE, REAL ESTATES & BUSINESS SERVICE

UTILITI (ELEKTRIK, GAS, AIR & PERKHIDMATAN PENJAGAAN KEBERSIHAN)UTILITIES (ELECTRICITY, GAS, WATER & SANITARY SERVICE)

LAIN-LAIN : NYATAKANOTHERS : SPECIFY

PENGANGKUTAN, GUDANG & KOMUNIKASI TRANSPORTATION, WAREHOUSE & COMMUNICATION

COP RASMI SYARIKATCOMPANY OFFICAL STAMP

TANDATANGANSIGNATURE

TARIKHDATE

Ibu Pejabat NIOSH, (Selangor)

Faks : 03 - 8926 3900 (HETD)Tel : 03 - 8911 3815/ 3819 (HETD)

E-mel : training@niosh.com.my

Pejabat Wilayah Selatan

Tel : 07 - 599 1200 (Johor) : 06 - 232 6855/ 66 (Melaka)Faks : 07 - 599 0200 (Johor) : 06 - 232 6805 (Melaka)E-mel : johor@niosh.com.my : melaka@niosh.com.my

Pejabat Wilayah Utara (P.Pinang)

Tel : 04 - 380 1200Faks : 04 - 397 3977E-mel : penang@niosh.com.my

Pejabat Wilayah Pantai Timur (Kemaman)

Tel : 09 - 859 9961/ 62Faks : 09 - 859 9960E-mel : terengganu@niosh.com.my

Pejabat Wilayah Sabah

Tel : 088 - 264 252 (Kota Kinabalu) : 087 - 423 254/ 408 778 (Labuan)Faks : 088 - 263 252 (Kota Kinabalu) :087 - 423 255 (Labuan)E-mel : sabah@niosh.com.my

NO. CEKCHEQUE NO.

TARIKH KEAHLIANDATE OF MEMBERSHIP

00.MR

TARIKHDATE

1. Sila pastikan cek dibayar atas nama “NIOSH”. No. akaun NIOSH : 5122 6840 2410 (Maybank, Cawangan Bandar Baru Bangi). Please ensure that cheque is payable to “NIOSH” . NIOSH account no : 5122 6840 2410 (Maybank, Bandar Baru Bangi Branch).

2. Jangan hantarkan wang tunai menerusi pos. Do not send cash through mail.

3. NIOSH berhak untuk menolak permohonan yang tidak lengkap. NIOSH has the right to reject incomplete application.

Pejabat Wilayah Sarawak

Tel : 086 - 311 500/ 330 600 (Bintulu) : 082 - 256 500/ 241 800 (Kuching) : 085 - 406 085/ 071 (Miri)Faks : 086 - 315 501 (Bintulu) : 082 - 253 020 (Kuching) : 085 - 406 086 (Miri)E-mel : sarawak@niosh.com.my

1

PSMB/GRIP/1/15

1MALAYSIA GLOBALLY RECOGNISED INDUSTRY AND PROFESSIONAL

CERTIFICATION

(1MALAYSIAGRIP)

Employee of HRDF Registered Employer

Employee of Non Registered Employer with HRDF

Please tick (√) where applicable

Please tick (√)

1 Course Title :

2 Start Date :

3 Completion Date :

4 Venue :

5 Training Provider :

Copy of MyID (Identity Card)

Copy of Latest 1 Month Pay Slip

A. TRAINING INFORMATION

APPLICATION FORM

CATEGORY OF EMPLOYEE

SUPPORTING DOCUMENTS TO BE ATTACHED

2

1 Name :

2 MyID Card No. :

3 Gender : Male Female

4 Address :

Postcode State:

5 Tel. No (Office) :

6 Tel. No (Handphone) :

7 Email :

8 Social Media

Preference (please

provide ID)

: LinkedIn : ……………………………………………………..

Facebook : ……………………………………………………..

Others : …………………………………………………………..

9 Academic

Qualification

: Sijil Pelajaran Malaysia (SPM)

Sijil Tinggi Pelajaran Malaysia (STPM)

Certificate / Skills Certificate

Diploma

Bachelor Degree

Master Degree

Doctoral Degree

Others: ………………………………………

10 Specify Highest

Academic

Qualification;

eg. Bachelor of Economics

:

- -

B) TRAINEE INFORMATION

3

11 Current Position : Manager Professional Technicians & Associate

Clerical Support Workers Service and Sales Workers

Skilled Agricultural, Forestry & Fishery Workers

Craft and Related Trades Elementary Occupations

Plant and Machine – Operators and Assemblers

12 Exact Position :

13 Current Monthly

Salary Range

: Below RM800 for Sabah and Sarawak

Below RM900 for Peninsular Malaysia

RM800 to RM1,999 for Sabah & Sarawak RM900 to RM1,999 for Sabah & Sarawak RM900 to RM1,999 Peninsular Malaysia

RM2,000 to RM3,999 RM4,000 to RM5,999 RM6,000 to RM7,999 RM8,000 to RM9,999

RM10,000 and above

1 Name of Employer :

2 MyCoID (Company

Registration Number)

- Compulsory

:

3 Industry : Manufacturing Service Agriculture

Construction Mining & Quarrying

Specify Sub sector:

4 Address :

Poscode State

(C) EMPLOYER INFORMATION

4

5 Tel. No (Office) :

6 Fax . No. :

7 Contact Person (HR) :

8 HR Email Address :

Signature : ...........................................…….. Company Stamp:

Name : ……………………………………….

Position : ………………………………………..

Date : ………………………………….......

Signature : ...........................................………………………………

Name : …………………………………………………………………

MyID Card No. : …………………………………………………………………

Date : ………………………………………………………………...

I hereby declare that the above mentioned trainee is an employee of our company

I declare that the facts stated in this application and the accompanying information are true and correct and

I have not withheld / distorted any material fact.

D. EMPLOYER ENDORSEMENT

E. EMPLOYEE ENDORSEMENT