LAPORAN JAWATANKUASA LATIHAN KEMENTERIANIJABATAN UNTUK KURSUS DALAM PERKHIDMATAN

(Borang ini hendaklah DITAIP)

........................................................................ (Tandatangan Pengerusilsetiausaha)

Calon Sim~anan

1. Nama : Jawatan:

2. Nama: Jawatan:

Nama :

Jawatan:

Cop Rasmi Kerajaan:

Tarikh: ................................ : .........

PERAKUAN

DENGAN PERAKUAN IN1 KETUA JABATANI KEMENTERIAN BERSETUJU MELULUSKAN PEGAWAI UNTUK BERKURSUS

JPAQLDP 1B/%

Sile nyateken sebabnya jika belum disahkan

P .

0 sib kosongken nema berkaitan

BAHAGIAN LATIHAN JABATAN PERKHIMATAN AWAM

PERMOHONAN MENGIKUn KURSUS DALAM PERKHIDMATAN ARAHAN:

1. Lengkapkan borang dengan jelas, sila tujuk panduan kod di mana. berkaitan.

2. Perlu diisi dalam DUA (2) salinan. 3. Senarai tugas perlu diserbkan.

,

Gambar

A BUTIR-BUTIR DlRl

1. Nama Penuh

I

2. No. KPT 1-1 - - 7 1 3. No. U P -1 4. Tarikh Lahir 1 7 1 r l 1 7 3

_.. (Hari) (Bulan) (Tahun)

5. Negeri Lahir I) (rujuk panduan kod) 6. Taraf Perkhawinan 0 K - Kahwin B - Bujang

7. Jantina 0 L - Lelaki P - Perempuan 8. Keturunan I] (rujuk panduan kod)

9. Agama 0 I- Islam L - Lain-lain 10. Kecacatan 0 (rujuk panduan kod)

1 1. Orang yang boleh dihubungi semasa kecemasan. Nama : Alamat :

No. Telefon :

6. BUTIR-BUTIR PERHIDMATAN SEKARANG

12. Klasifikasi 0 (rujuk panduan kod) 18. Kementerian : Perkhidmatan

13. Skim 19. Jabatan : Perhidmatan

1 . 1 I I I I I 14. Gred Jawatan m l 20. Jenis Agensi 0 (rujuk panduan kod)

15. Tanggagaji: PO TD 21. Alamat Tempat Bertugas :

16. Tarikh Lantikan :

m m UIIn (Hari) (Bulan) (Tahun)

17. Tarikh Disahkan 22. Telefon (a) Pej m a = (b) Rumah (Hari) (Bulan) (Tahun) No. Fax:

e-mail :

23. Lantikan pertama ke PERKHIDMATAN KERAJAAN jika lain dari 13 (a) Skim Perkhidmatan:

(b) Tarikh Lantikan :

,

32. Biasiswa yang pernah diterima :

Penaja TarikhlTempoh Biasiswa Kursus Yang Dikuti Tempoh Kontrak

>

C. BUTIR-BUTIR AKADEMIK

24. Kelayakan : (a) Sijil

(b) Diploma

(c) ljazah Pertama - .. - . -.

(d) Ph. DISarjana Dip. Lepasan ljazah

0

D. B,UTIR-BUTIR KURSUS YANG DIPOHON

25. Nama Kursus

26. Peringkat Kursus

27. Nama lnstiiusi

28. TempattNegara

29. TarikhITempat Kursus : - 1 ( bulan)

30. Penganjur

E. KURSUS YANG PERNAH DllKUTUBlASlSWA YANG PERNAH DKERlMA

31. Kursus yang pernah diikuti dalam tempoh 2 tahun yang lepas ( Sila buat lampiran jika mang tidak mencukupi)

Nama Kursus Anjuran Tempat Tempatrrarikh

KelaslCGPA Bidang & InstltusilUniversiti

- . - . .- - . - . . -

Tahun

J

i PENGAKUAN PEMOHON (Potonq yang tidak berkaitan)

(a) Saya telahlbelum mengisytiharkan harta. (b) Saya telahlbelum menerima elaun pakaian panas pada (c) Saya mengaku bahawa semua keterangan di atas adalah benar.

Sekiranya kenyataan yang diberikan tidak benar, JPA berhak membatalkan permohonan atau Hadiah Latihan ini.

G. PERAKUAN KETUA JABATAN (Potong yanq tidak berkaitan)

Tarikh : ( Tandatangan Pemohon )

P4. (a) Sokongan Disokong I Tidak Disokong

(b) TINDAKAN TATATERTIB Ada 1 Tiada

(c) Markah Laporan ~i laian Prestasi Tahunan

(i) Tahun : Markah : (ii) Tahun : Markah : (iii) Tahun : Markah

(iv) Purata Markah :

(d) Pegawai BOLEH / TlDAK BOLEH dilepaskan untuk mengikuti kursus yang dipohon.

Saya mengesahkan bahawa semua kenyataan yang diberikan oleh adalah benar.

Tarikh : (Tandatangan Ketua Jabatan )

Nama :

Jawatan : Cop Rasmi Jabatan :

H. UNTUK KEGUNAAN JPA (BAHAGIAN LATIHAN)

Program LDP T I 36. Tahun.Penajaan -1 37. Bil -1

I Peringkat Pengajian

Nama Kursus :

39. Negara 1 -1 Negara2 -1 (jika ada)

Bidang :

lnstitusi :

Tarikh Kursus

I D r E E n (Hari) (Bulan) (Tahun)

TAMAT a m nxrEl (Hari) (Bulan) (Tahun)

Jenis Cuti Belajar I Hadiah Latihan

Surat Kelulusan 777 47. Tempoh Kontrak ( dalam tahun )

(Jika ada)

A BUTIR-BUTIR DlRl

PANDUANKOD

5 Negeri Lahir

L

01 Johor 02 Kedah 03 Kelantan 04 Melaka 05 Negeri Sembilan 06 Pahang 07 Perak 08 Perlis 09 Pulau Pfnang 10 Selangor 11 Terengganu 12 Wilayah Persekutuan 13 Sabah 14 Sarawak 15 Lain-lain 16 Wilayah Persekutuan Labuan

8. Keturunan

01 Melayu 02 Clna 03 India 04 Orang As15 Semenanjung 07 Kadazan KawekanlDusun 08 Murut 09 Bajau, llanau 10 Lain-lain Bumiputera Sabah 13 Melanau 14 lban 15 Bidayuh 16 Lain-lain Bumiputera Sarawak 17 Lain-lain

10. Kecacatan

B BUTIR-BUTIR PERKHIDMATAN SEKARANG

12 Klasifikasi perkhidmatan

A Pengangkutan B Bakat dan Seni C Sains D Pendidlkan E Ekonomi F Sistem Maklumat G Pertanian J Kejuruteraan K Keselamatan dan Pertahanan Awam L Perundangan M Tadbir dan Dlplomatik N Pentadbiran dan Pembangunan Q Penyelldikan dan Pembangunan R MahirlSeparuh MahIrTTidak Mahir S Sosial U Perubatan dan Keslhatan W Kewangan P Polis T Tentera

14. Gred Jawatan

Contot DSI=

20. Jenis Agensl

1 Perkhidmatan Awam Persekutuan 2 Perkkhidmatan Awam Negeri 3 Badan Berkanun Persekutuan 4 Badan Berkanun Negerl 5 Penguasa Tempatan 6 Syarikat Kepentingan Kerajaan 7 Swasta

Buta Buta Warna Mendengar dengan alat bantuan Pekak B k u Gagap Cacat Kaki Cacat Tangan Lumpuh . Kecacatan Lain

Form A3.43

Technical Cooperation by The Government of Japan Training Award of Japan International Cooperation Agency ( J I C A )

Application by the Government of

................................................................................................... for a training course in the field oi '

. - - . - (FOR JAPANESE OFFICIAL USE)

........................ IJ Ordinary Group Course (Sef = - x ) Course No.

................................. 0 Special Group Course (-&#S) Course No.

0 Country-focused Group Course (B~~J%%)

....................................... 0 Counterpart (A 3 9 jr - ye - E ) W P l X %

0 Ordinary Individual Course (4faS3-B) 0 0r;lers (c. s . RBJ~SII'HF)

Please provide one original and three copies. Please print or type.

P,4RT A To be completed by the nominee.

1 FULL NAME (as in Passport, underline Fzmily Name) -m

1 2 ADDRESS FOR CORRESPONDENCE I 4 DATE OF BIRTH 1 5 AGE I I Month I ate I Year I I

Telephone : 1 I I I 3 NAME AND ADDRESS OF PERSON TO BE

NOTIFIED IN CASE OF EMERGENCY

Relationship to you: Telephone:

7 MARITAL STATUS GSINGLE @MARRED

I 8 NATIONALITY I

10 EDUCATIONAL RECORD

11 TRAINING OR STUDY IN FOREIGN COUNTRIES (in relation to professional interests.)

Instiiution

i

Qualification Obtained

Subject

. .

~it; /~ountrv

,

Institution City/Country

Years Attended

Period

. From

Certificate/ Degree Awarded

.

From

To

Field of Study To

12 EMPLOYMENT RECORD

1) Present Place of Employment

Name

Address

Telephone: TelexEax:

2) Previous Job

Name and Address of Organization

Previous Title/Post and Dates(from/to)

Title of Present Job

Date of Taking Up Post

Type of Organization

0 Governrnental/Public 0 Private 0 International 0 Others

Description of Your Previous Job

3) Describe briefly the work of your organization and the service it provides. .

................................................................................................................................................ 4) Describe your own job.

................................................................................................................................................ 5 ) Explain how the proposed training will be of benefit to you in the work you will be doing on your

return.

13 LANGUAGE PROFICIENCY

1. English Listening 0 excellent 0 good 0 fair 0 poor Speaking 0 excellent 0 good fair 0 poor

... WritingIReading 0 excellent 0 good fair a poor 2- blother Tongue ..................................................................................................................... 3. Other Lanl3Wv .............................................. : ......................................................................

0 excellent 0 good 0 fair 0 poor

14 NOMINEE'S DECLARATION To be signed by the nominee.

I certify that the statements made by me in this form are true and correct to the best of my knowledge.

If accepted for a training award, I agree:

(a) not to bring any member of my family. (b) to carry out such instructions and abide by such conditions as may be stipulated by both the

nominating Government and the Japanese Government in respect of this course of training. (c) to follow the course of study or training. and abide by the rules of the institution or establishments

with which I undertake to study or train. (d) to refrain from engaging in political activities, or any form of employment for. profit or gain. (e) to submit any progress report or evaluation ques t io~a i r e s which may be prescribed. (f) to return to my home country a t the end of my course of study or training.

I also fully understand that if granted a training award it may be subsequently withdraw if I fail to make adequate progress, or for other sufficient cause including physical conditions determined by.the Government of Japan.

Date: ............................................................ s ima tue : ............................................................ +

PART B To be completed by nominee's Director or Head of Department. OBSERVATIONS OF NOMINATING ORGANIZATION 1 Describe what work the nominee will be expected to do on his return.

2 Explain how the proposed training will be of benefit to the work of your organization.

3 (For Non-Group Training only) Describe: 1) Subject area of the training required.

2) Special subjects which are particularly important and should be included in the training program (continue on i n additional sheet if necessary).

3) Period of training required (from/to) . .

............................................................................................................................................. 4) Notice required before nominee can be released from present post:

.............................................................................................................................................

PART C To be completed and signed by a responsible govenunent official. OFFICIAL NOMINATION

I certify that:

1 I haveexamined the documents in.this fonn and I am satisfied that they are authentic and relate to I I the nominee. I I accordingly nominate this person on behalf of the

Government of ...................................................

.......................................... Date: ....................................... Signature: .- ..--. - -. Position: ................................. Name:. ...............................................

Official stamp

.................................... Organization:

.........

MEDICAL HISTORY AND EXAMINATION FOR JICA TRAINING AWARD

8 IMPORTAiiT NOTICE Before you complete the Medical History Questionnaire. you are hereby notified that:

MEDICAL HISTORY TO BE COMPLETED BY NOMINEE

1. NAME OF NOMINEE(1ast name, first name. middle name)

A medical condition resulting from an undisclosed pre-existing condition may not be financially compen.sated for by JICA and may result in termination of your training program.

I understand and accept the terms of this notice. - Yes - No

2 DATE OF BIRTH (molday/yr)

6 NAME OF TRAINING COURSE/SEMINAR

7 LENGTH OF TRAINING COURSE/SEMINAR (weeks. months)

3 NATIONALITY

. .

4 SEX male female

5 ADDRESS FOR CONTACT

9 NOMINEE WILL CHECK "YES" OR "NO" AND EXPLAIN

10 NOMINEE WILL INDICATE "YES" OR "NO" TO EACH ITEM DO YOU NOW HAVE OR HAVE YOU EVER HAD THE CONDITIONS LISTED BELOW?

a.

b.

c.

d.

.

(Check each item. if yes. enclose the relevant condition vbith'a circle.)

CONDITION

Asthma. emphysema. or other lung conditions . Tuberculosis or live with anyone who has tuberculosis

High blood pressure. heart disease Stomach, liver (hepatitis). gall bladder disease Kidney or bladder disease, stone or blood in urine Diabetes (sugar in the urine) Depression, excess w o w , attempted suicide, or other psychological symptoms Acquired Immune Deficiency Syndrome (AIDS) Tumor, abnormal growth. cyst. or cancer Bleeding disorder, blood disease (sickle cell anemia)

YES

I CERTIFY THAT I HAVE READ T H E ABOVE INSTRUCTIONS AND ANSWERED AU QUESTIONS TRULY AND COMPLETELY TO THE BEST OF MY KNOWLEDGE.

EXPLANATION N O

11 PRINTED NAME OF NOMINEE

I Do you currently use any drugs for treat- ment .of a medial condition? (Give name & dose.)

Have you ever been a patient in a mental hospital or sanitarium or treated by a Psychiatrist? (Give place & dates.)

Have you had any significant or serious illness or injury? (If hospitalized. give place & dates.) ,

Have you had any operations or advised by a physician to have an operation? (Give place & dates.)

12 DATE 13 SIGNATURE OF NOMINEE

Advance Information of Prospective Candidate - -

Name & No. Of Course

Name of Candidate

Sex

4. Date of Birth

Qualification Or Final Education Background

Name & Place of SchooVUniv~ity

State Year of Graduation

Ability of Spoken English :

Ability of Writen English :

Started Work In ( give date)

10. Present Post

Male Female

A B C D (excellent) (good) (average) (poor)

(state position, place Bt under which Ministry)