1) Butiran Peribadi Pemohon
Gelaran * :
Y.B.M.
Y.M.
Prof.
Dr.
Tuan
Puan
Encik
Cik
Nama Penuh * :
Jenis KP * :
No. KP * :
-
-
No. KP Lama / Polis / Tentera
* :
Negeri Kelahiran * :
Johor
Kedah
Kelantan
Melaka
Negeri Sembilan
Pahang
Pulau Pinang
Perak
Perlis
Selangor
Terengganu
Sabah
Sarawak
Wilayah Persekutuan (Kuala Lumpur)
Wilayah Persekutuan (Labuan)
Wilayah Persekutuan (Putrajaya)
Lain-Lain
Tarikh Lahir * :
- -
Jantina * :
Taraf Perkahwinan * :
-- Sila Pilih --
Belum Berkahwin
Berkahwin
Duda / Janda
Keturunan * :
-- Sila Pilih --
Melayu
Cina
India
Lain-lain
Agama * :
-- Sila Pilih --
Islam
Buddha
Hindu
Kristian
Lain-lain
Alamat Tetap * : Cth: [ NO. 1, ]
[ JALAN TAMAN 1, ]
[ TAMAN PERUMAHAN ]
Bandar * :
Poskod * :
Negeri * :
-- Sila Pilih --
Johor
Kedah
Kelantan
Melaka
Negeri Sembilan
Pahang
Pulau Pinang
Perak
Perlis
Selangor
Terengganu
Sabah
Sarawak
Wilayah Persekutuan (Kuala Lumpur)
Wilayah Persekutuan (Labuan)
Wilayah Persekutuan (Putrajaya)
Lain-Lain
Negara * :
-- Sila Pilih --
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antartica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo (Zaire)
Congo, The Democratic Rupblic Of The
Cook Island
Costa Rica
Cote D’ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakstan
Kenya
Kiribati
Korea, Democratic People’s Republic Of
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People’s Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts And Nevis
Saint Lucia
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S
Wallis And Futuna
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
Kategori Permohonan * :
-- Sila Pilih --
Permohonan Baru
Peningkatan Secara Lantikan (PSL)
Peningkatan Kerjaya
Lain-Lain
Warganegara * :
Status OKU * :
Jenis OKU * :
2) Butiran Perhubungan
Alamat Surat-Menyurat *
Sama seperti di atas :
Cth: [ NO. 1, ] [ JALAN TAMAN 1, ] [ TAMAN PERUMAHAN ]
Bandar * :
Poskod * :
Negeri * :
-- Sila Pilih --
Johor
Kedah
Kelantan
Melaka
Negeri Sembilan
Pahang
Pulau Pinang
Perak
Perlis
Selangor
Terengganu
Sabah
Sarawak
Wilayah Persekutuan (Kuala Lumpur)
Wilayah Persekutuan (Labuan)
Wilayah Persekutuan (Putrajaya)
Lain-Lain
Negara * :
-- Sila Pilih --
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antartica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo (Zaire)
Congo, The Democratic Rupblic Of The
Cook Island
Costa Rica
Cote D’ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakstan
Kenya
Kiribati
Korea, Democratic People’s Republic Of
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People’s Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts And Nevis
Saint Lucia
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S
Wallis And Futuna
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
No. Telefon Bimbit * : Cth: 16/17/19xxxxxxx
No. Telefon (Rumah) : Cth: 7xxxxxxx
E-mel * : Cth: yourmail@mail.com (Google Mail)
Butiran Log Masuk
ID Log Masuk :
Katalaluan * :
Pengesahan Katalaluan * :
Soalan Keselamatan * :
-- Sila Pilih --
Siapakah nama ibu anda?
Siapakah nama ayah anda?
Siapakah nama kawan baik anda?
Siapakah nama idola hidup anda?
Apakah hobi anda?
Apakah nama binatang peliharaan anda?
(Untuk kegunaan apabila anda lupa katalaluan)
Jawapan Anda * :
Masukkan Kod Pengesahan * :
Pernyataan Pengakuan
Di bawah Seksyen 5, Akta Suruhanjaya-suruhanjaya Perkhidmatan 1957 (Semakan 1 Disember 2012), mana-mana individu yang berkait dengan suatu permohonan pekerjaan atau perlantikan dalam perkhidmatan awam atau mana-mana organisasi, dengan sengaja memberi maklumat yang palsu atau mengelirukan dalam apa jua bentuk, jika disabitkan boleh dihukum penjara dua (2) tahun atau denda dua ribu Ringgit Malaysia (RM2000) atau kedua-duanya sekali.
Saya akui bahawa maklumat yang diberi adalah benar dan sekiranya maklumat itu didapati palsu, permohonan saya akan terbatal dan sekiranya saya telah ditawarkan, perkhidmatan saya akan ditamatkan serta-merta.
Saya Setuju