BORANG KSM 01/01 (Pindaan: 1 Julai 2001) (FORM KSM 01/01) (Revision: 1 July 2001)

Gambar Berukuran

Pasport

Kerajaan Malaysia Berhak Meminda Borang Permohonan Ini Tanpa Sebarang Notis

( The Government of Malaysia Reserves the Right to Revise the Application Form Without Prior Notice)

(Passport Size Photograph)

PERMOHONAN UNTUK MENDAPATKAN INSENTIF DI BAWAH PROGRAM MENGGALAKKAN

WARGANEGARA MALAYSIA YANG BERKEPAKARAN YANG BEKERJA DI LUAR NEGARA PULANG KE MALAYSIA

(APPLICATION FOR INCENTIVES UNDER THE PROGRAMME TO ENCOURAGE MALAYSIAN CITIZENS

WITH EXPERTISE RESIDING OVERSEAS TO RETURN TO MALAYSIA

OBJEKTIF PROGRAM: MEWUJUDKAN TENAGA KERJA BERTARAF DUNIA (PROGRAMME OBJECTIVE: CREATING A WORLD CLASS WORKFORCE)

MAKLUMAT PEMOHON: (APPLICANT DETAILS) 1. Nama: _____________________________________________________________________________ (Name): 2. Nombor kad pengenalan: _________________________(Baru) /________________________ (Lama) (New/old identity card number): 3. Kewarganegaraan:___________________________________________________________________ (Citizenship): 4. Nombor Pasport Malaysia: _______________________________________(Sertakan salinan pasport) (Malaysian Passport number): (Attach copy of passport) 5. Alamat surat menyurat di luar negara dan Malaysia: _______________________________________

(Correspondence address overseas and in Malaysia):

6. Nombor telefon/alamat e-mail di luar negara dan Malaysia: _________________________________ (Telephone number/e-mail address overseas and in Malaysia): 7. Sekiranya sudah pulang ke Malaysia, sila nyatakan tarikh pulang:______________________________ (Sila sertakan salinan pasport bercop yang menunjukkan tarikh pulang ke Malaysia) (If you have already returned to Malaysia, please state your date of return): (Please attach copy of your passport which states your date of return) 8. Taraf pendidikan (Sertakan salinan sijil. Sekiranya sijil asal adalah dalam bahasa asing selain daripada

atau Bahasa Inggeris, sila sertakan salinan yang diterjemahkan). (Educational status. Please attach copy of certificates. Certificates in foreign languages other than English, please attach copy of the translation)

9. Adakah anda penerima biasiswa/pinjaman pelajaran dari mana-mana agensi?Jika ya, sila nyatakan

butiran lengkap penaja biasiswa/pinjaman: _________________________________ (Please confirm if you have received sponsorship from any agencies to further your education abroad; Please give details of the sponsorship received)

Kelulusan Akedemik

(Academic Qualification) Penaja

(Sponsor) Jenis Tajaan

(Biasiswa/ Pinjaman) (Type of Sponsorship)

(Scholarship/Loan)

Kerajaan Malaysia Berhak Meminda Borang Permohonan Ini Tanpa Sebarang Notis

( The Government of Malaysia Reserves the Right to Revise the Application Form Without Prior Notice)

10. Pengalaman bekerja lengkap. (Sila sertakan salinan surat tawaran pekerjaan sekarang): (Detailed work experience. Please attach copy of offer letter of current employment)):

Tempat-Tempat Bekerja Di Luar

Negara (Places Of

Employment Overseas)

Bulan & Tahun Dari - Sehingga (Month & Year)

(From – To)

Tempoh (Duration)

Bidang Kepakaran (Field Of Expertise)

11. Sila sertakan keterangan diri :

(Please attach curriculum vitae):

12. Cadangan pekerjaan di Malaysia:________________________________________________________ (Proposed working plan in Malaysia):

13. a. Adakah isteri/suami telah memohon di bawah Program ini: Ya/tidak (Please confirm if your spouse has applied under this Programme: Yes/No)

b. Adakah tuan/pasangan pernah memohon di bawah Program ini sejak Program ini dikuatkuasakan pada 1 Januari 2001 : Ya/Tidak

(Please confirm if you/spouse have applied before under this Programme since this Programme was implemented on 1st January 2001: Yes/No)

MAKLUMAT KELUARGA (FAMILY DETAILS) 1. Nama isteri/suami: _________________________________________(Sila sertakan salinan Sijil Nikah)

(Spouse name): (Please attach Copy of Marriage Certificate)

2. Warganegara isteri/suami: _____________________________________________________________ (Spouse citizenship):

3. Nombor pasport isteri/suami:______________________________________ (Sertakan salinan pasport)

(Spouse passport number) : (Please attach copy of passport)

4. Bilangan anak: _________________________________(Sertakan salinan Sijil Kelahiran dan pasport ) (Number of children): (Please attach copy of Birth Certificates and passports) 5. Kewarganegaraan anak:______________________________________________________________ (Citizenship of children):

PENGAKUAN PEMOHON: Saya mengesahkan bahawa:

i. Saya percaya semua maklumat yang diberikan dalam borang ini dan dokumen yang disertakan adalah benar; ii. Sekiranya permohonan saya diluluskan dan saya bersetuju menerima insentif yang ditawarkan, saya bersetuju untuk bekerja di Malaysia sekurang-kurangnya lima (5) tahun; iii. Sekiranya permohonan saya diluluskan dan saya bersetuju menerima insentif yang ditawarkan, saya bersetuju untuk melaporkan diri kepada penaja (biasiswa / pinjaman) sebaik sahaja kembali ke Malaysia (untuk pemohon yang menerima biasiswa / pinjaman untuk melanjutkan pelajaran ke luar negara); iv. Saya faham dan bersetuju sekiranya di dalam pengetahuan saya didapati terdapat maklumat yang tidak benar dan / atau dokumen palsu untuk memohon insentif dan / atau saya tidak mematuhi syarat untuk bekerja di Malaysia selama lima (5) tahun seperti di perenggan (ii) di atas, insentif yang telah diterima akan ditarik balik; v. Pihak berkuasa berhak menuntut apa-apa bayaran (duti import, duti eksais, cukai jualan dan lain-lain) ke atas saya atau waris bagi semua pelepasan yang telah saya terima di bawah program khas ini; dan

vi. Saya bersetuju sekiranya permohonan saya diluluskan di bawah Program Khas ini, butir-butir peribadi saya seperti nama, bidang kepakaran, kelulusan akademik dan nombor untuk dihubungi akan dimasukkan ke dalam laman web rasmi Kementerian Sumber Manusia.

I declare that:

i. I verily believe that all the information provided in this form and documents annexed herewith are true and correct; ii. If my application is approved and I agree to receive the incentives, I agree to work in Malaysia for at least five (5) years; iii. If my application is approved and I agree to receive the incentives, I agree to report myself to the sponsor when I return to Malaysia (For applicants who received scholarship/loans to study abroad); iv. I understand and agree that, if it is within my knowledge I submitted false information, particulars and/or documents for the purpose of applying this incentives and/ or do not comply with the condition in para (ii) above, the incentives received shall be withdrawn; v. In relation with the above, the authority shall demand any payment(duty import, duty excise, sales tax and etc), that has been forwarded to me under this special program for myself, successors or heirs; vi. I understand and agree that legal action can be taken upon me according to the jurisdiction of the Law in Malaysia if I submitted false information, particulars and/ or documents and/ or do not comply with the conditions stated.

vii. I agree if my application is approved under this Programme, my details such as name, field of expertise, academic qualification and contact number will be listed in the MoHR website. ------------------------------------------------- (Tandatangan/Signature) ( ) (Nama/Name) Tarikh:_________________ (Date): Program Ini Berkuatkuasa Mulai 1 Januari 2001 (This Programme Is Effective From 1 January 2001) Dikemaskini pada: 22 Mei 2007 (Updated on: 22 May 2007)

Kerajaan Malaysia Berhak Meminda Borang Permohonan Ini Tanpa Sebarang Notis

( The Government of Malaysia Reserves the Right to Revise the Application Form Without Prior Notice)