Thursday, 15 September 2016 14:58

BORANG TABUNG BANTUAN SEJAMBAK KASIH

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KEMBARAN A KEPADA

KP/BPA/CSA (KEB)/3076/2A

BERTARIKH 05 JUL 96

PERMOHONAN TABUNG BANTUAN SEJAMBAK KASIH

 1.         Butir-butir Permohonan:

 a.        Nama :...................................................................................................................

b.        No Ten & Pangkat :...............................................................................................

c.         Pasukan :.............................................................................................................

d.        Alamat             :....................................................................................................

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

e.         Tarikh Masuk Tentera :.........................................................................................

f.          Jumlah Tanggungan : ...........................................................................................

g.            Tugas Jawatan Sekarang :...................................................................................

 

2.         Butir-butir Pesakit:

a.            Nama :..................................................................................................................

b.            Pertalian :..............................................................................................................

c.            Umur :..................................................................................................................

d.            Jenis Penyakit :.....................................................................................................

 

3.         Saya mengesahkan maklumat-maklumat di atas adalah benar.

 

 

 

           

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

                                                                                                           Tandatangan Pemohon

 

 

BAHAGIAN I

(Hendaklah dipenuhkan  Oleh Pegawai Perubatan Unit)

 

4.         Permohonan disokong/tidak disokong

 

5.         Ulasan tentang pesakit :

 

 

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

                                                                                                          Tandatangan

 

                                                                                  Nama :...................................................................

                                                                                  Pangkat :................................................................

                                                                                  Jawatan :................................................................

                                                                                  No.Tentera :...........................................................

 

Cop Rasmi

 

 BAHAGIAN II

((Hendaklah dipenuhkan  Oleh Pegawai Memerintah)

 

6.         Saya sahkan dari keterangan dan bukti yang di perolehi bahawa Pegawai/LLP yang tersebut di atas adalah anggota dari pasukan saya.

 

 

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

                                                                                                       Tandatangan Pegawai Memerintah

 

 

Cop Rasmi     :                                                                                 Nama : ..........................................

Pangkat : ......................................

No.Tentera : .................................                                                  

 

BAHAGIAN III

(Hendaklah dipenuhkan oleh Markas/Departmen Perkhidmatan)

 

7.         Permohonan disokong/tidak disokong.        

 

 

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

                       

                                                                                                                          Tandatangan

 

                                                                                                          Nama : ..........................................

Cop Rasmi     :                                                                                  Pangkat : .......................................

 Jawatan : ......................................

No. Tentera : ................................

________________________________________________________________________________

 

BAHAGIAN IV

(Catatan Oleh Lembaga Tabung Sejambak Kasih)

 

8.         Ulasan Lembaga:       ..................................................................................................................................................................

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

 

9.         Keputusan Lembaga:             Diluluskan  /  Tidak Diluluskan

 

 

 

 

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

Cop Rasmi

Tandatangan Pengerusi       

 

 

 

 

Borang Permohonan ini hendaklah disediakan di dalam tiga (3) salinan.

 

 

**MUAT TURUN BORANG DISINI**

 

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