Kod ID / ID Code / 识别证编号:

Daerah (IPD) / Negeri :

BORANG PENDAFTARAN

REGISTRATION FORM 登记表格

**Maklumat WAJIB / Compulsory Details/ 强制性资料

Julai 2016

COMMUNITY POLICING MALAYSIA (Program Kepolisan Komuniti Malaysia) C/O: No.27-2, Jalan PU 7/4, Taman Puchong Utama,

47140 Puchong, Selangor Darul Ehsan.

Tel: 03-8061 2044 Fax: 03-8068 5444

Website: www.cops.org.my

Facebook: cops.org.my Email: kuan@cops.org.my

1. Nama Cina (jika ada) / Chinese Name / 华文姓名(如有): ________________

2. Nama Penuh mengikut Kad Pengenalan / Full Name as in NRIC / 姓名**

3. No. Kad Pengenalan Baru / New I/C No. / 身份证号码** 4. Negeri Lahir / Birth State / 出生州属**

- -

5. Tarikh Lahir / Birth Date / 出生日期** 6. Umur / Age / 年龄** 7. Jantina / Gender / 性别**

- -

L / M / 男

P / F / 女

8. Pekerjaan / Occupation / 职业**

9. Alamat Semasa / Current Address / 现时住址**

10. No. Telefon Rumah / Home Phone No. / 住家电话号码 11. No. Telefon Bimbit / Handphone No. / 手机号码**

**Type [ON >space< CP] send SMS to 33555 for receive crime/CP info

12. Alamat E-mel / E-mail Address / 电子邮址

13. Balai Polis Berhampiran / Nearest Police Station / 邻近警察局 14. Daerah Polis / Police District / 所属警区

i) Kad ID/ ID Card /识别证 : Ahli Biasa/Ordinary Member/普通队员 RM50

EXCO/EXCO/领队 RM130

ii) Lencana/Badge/衣领徽章: Ahli Biasa/Ordinary Member/普通队员 RM10

EXCO/EXCO/领队 RM15

iii) Baju Korporat/Corporate Shirt/会衣 [size: S/M/L/XL] RM70

[size: 2XL/3XL/4XL] RM80

iv) Baju Polo T/Polo T-Shirt/衬衫 [size: S/M/L/XL] RM40

[size: 2XL/3XL/4XL] RM45

v) Baju Kolar Bulat/Roundneck T-Shirt/圆领衬衫 [size: S/M/L/XL] RM28

[size: 2XL/3XL/4XL] RM35

vi) Peti Lawatan CP/CP Visitation Box/巡逻信箱 RM65

ix) Pelekat Cermin/Windscreen Sticker/车镜贴纸 RM10

vii) Insurans Kemalangan Diri/P.A.Insurance/个人意外保险 RM30

x) Pelekat CP/CP Sticker/车尾 CP 贴纸 RM5

viii) Topi/Cap/帽子 RM20

xi) Sijil/Certificate/证书 RM10

**Tandatangan Pemohon / Applicant’s Signatory / 申请人签名 : ___________________________ Tarikh / Date / 日期 : _______________

Disokong Oleh / Seconded By / 介绍人 : _________________________________ No. Tel/ Handphone No./ 手机号码 : __________________

UNTUK KEGUNAAN PEJABAT / For Office Use / 供办事处之用

_____________________________ Tandatangan Pengurusan /

Authorized Signatory / 审核者签名

2 keping gambar

berukuran pasport +

Sesalinan Kad Pengenalan

2 piece of passport size

photo + 1 piece of IC

photocopy

2 张护照型人头照 +

1 张复印身份证

Sila lengkapkan semua bahagian borang dengan menggunakan HURUF BESAR dan tandakan (√ ) di kotak yang sesuai. Please complete all sections

of the form in BLOCK LETTERS and tick (√ ) in the appropriate boxes. 请用大字母填写表格，在相关格子内打(√ ) 符号。

Saya ingin memohon menjadi Ahli Sukarelawan Program Kepolisan Komuniti Malaysia dan butir-butir peribadi saya adalah seperti di bawah.

I would like to be a volunteer of Community Policing Malaysia and my particulars are as follows. 本人欲申请成为马来西亚人民社警计划志愿者，以下是

本人之个人资料。

SSYYAARRAATT DDAANN PPEERRAATTUURRAANN AAHHLLII SSUUKKAARREELLAAWWAANN CCOOMMMMUUNNIITTYY PPOOLLIICCIINNGG

((PPRROOGGRRAAMM KKEEPPOOLLIISSAANN KKOOMMUUNNIITTII MMAALLAAYYSSIIAA))

人人民民社社警警计计划划条条规规

1. Ahli Sukarelawan CP TIDAK MEMPUNYAI KUASA POLIS dan tidak boleh terlibat dalam salah guna dadah dan apa-

apa jua jenayah sepanjang keahliannya. Sekiranya ahli didapati bersabit dengan kesalahan dalam menyalahguna kuasa dan

terlibat dalam jenayah, keahliannya akan dilucutkan secara automatik. CP 成员没有警察权力，绝不可涉及任何犯罪活动。一

旦涉及滥用毒品及犯罪活动，或滥用权力，将自动丧失 CP 成员资格。

2. Ahli Sukarelawan CP yang ingin menjalankan rondaan sukarela di kawasan masing-masing perlu mendapat kelulusan

bertulis daripada Ketua Polis Balai atau Ketua Polis Daerah dari daerah masing-masing dan WAJIB MENDAPAT

KELULUSAN BERTULIS BERSAMA daripada Ibu Pejabat Community Policing Malaysia. Mana-mana Ahli

Sukarelawan CP yang gagal berbuat demikian, akan dipecat keahliannya dan segala peralatan dan pakaian yang dibeli,

mestilah dikembalikan kepada Ibu Pejabat CP di Puchong. CP 成员进行社区自愿巡逻任务之前，必须取得所属警区的警区主

任或警察局局长的批文，同时也必须经由人民社警总部的书面批准。凡违犯者可被开除 CP 成员资格，必须归还所有属于人民

社警的衣服、产品及用具。

3. Ahli Sukarelawan CP yang ingin menjalankan aktiviti, tugasan khas dan perkhidmatan masyarakat, melainkan rondaan

komuniti di kawasan masing-masing WAJIB MENDAPAT NASIHAT DAN KELULUSAN BERTULIS daripada ibu

pejabat Community Policing di Puchong. Mana-mana Ahli Sukarelawan CP yang gagal berbuat demikian, akan diambil

tindakan tatatertib yang tegas dan dipecat keahlian. 一切与人民社警计划有关的（非巡逻）活动、特别任务和社区服务，都必

须事先取得人民社警总部的批准，方可进行。凡违犯者可面对纪律对付以及被开除 CP 成员资格。

4. Ahli Sukarelawan CP WAJIB untuk menghadiri segala mesyuarat, rondaan yang dianjurkan oleh Community Policing

kawasan mereka. CP 成员必须出席一切会议及参与巡逻任务。

5. Ahli Sukarelawan CP WAJIB untuk mengenali jiran-jiran mereka dan memberi bantuan kepada jiran-jiran mereka

sekiranya diperlukan demi menjaga keamanan dan keselamatan komuniti mereka. CP 成员必须结识邻居促进合作，当邻里需

要帮助时伸出援手，共同维护社区安全水平。

6. Ahli Sukarelawan CP WAJIB untuk menggunakan Model SARA (Scanning, Analyse, Respond, Assessment) supaya

mengenalpasti masalah jenayah dan sosial yang wujud di kawasan mereka. CP 成员必须掌握 SARA法则以鉴定居住范围内

发生的治安与社会问题。

7. Ahli Sukarelawan CP WAJIB untuk membantu polis dan kerajaan dalam usaha pencegahan jenayah ke arah mencapai

matlamat NKRA dalam aspek pengurangan jenayah demi menjaga keselamatan dan keamanan komuniti dan negara. CP 成

员必须协助警方减少罪案，以达致国家关键绩效领域降低罪案的目标，以维护社区治安与国家稳定。

8. Ahli Sukarelawan CP WAJIB mempunyai perwatakan baik, tidak boleh menggunakan bahasa kesat dan berkelakuan tidak

tertib, mesti berpakaian kemas serta berambut pendek. Pakaian seragam/uniform hanya boleh dipakai ketika dan waktu

bertugas atau dalam majlis rasmi sahaja. CP 成员必须注意形象及言行、不可做出任何不检行为、保持衣装整洁、禁止蓄长

发。除了进行任务或出席正式场合之外，CP 成员禁止穿上制服/会衣。

9. Ahli Sukarelawan CP WAJIB memberi bantuan dalam pengurusan khairat kematian apabila diperlukan. CP 成员在需要时必

须协助同僚处理家属之丧礼，以表同心同德精神。

10. Ahli Sukarelawan CP mesti memperolehi ilmu undang-undang untuk menjadi seorang yang berdisiplin dan berhemah.

CP 成员必须学习及了解各种法律以贯彻自律精神与保持良好操守。

11. Ahli Sukarelawan CP tidak dibenarkan mengeluarkan apa-apa kenyataan media dan menerima temuramah media tanpa

kelulusan sah daripada Ibu Pejabat Community Policing Malaysia. Mana-mana Ahli Sukarelawan CP yang gagal berbuat

demikian, akan diambil tindakan tatatertib yang tegas dan dipecat keahlian. 未经人民社警总部批准下，CP 成员不可接受任

何媒体访问或发表任何文告。凡违犯者可面对纪律对付以及被开除 CP 成员资格。

*****************************************************************************************************************

AAKKUUAANN 宣宣誓誓声声明明

1. Saya mengaku bahawa saya memahami dan mematuhi segala syarat dan peraturan sebagai Ahli Sukarelawan

Community Policing. Saya mengaku dan bersumpah saya tidak mempunyai rekod jenayah dan bebas dari

jenayah dadah dan saya faham keahlian saya TIDAK MEMPUNYAI KUASA POLIS. 本人完全理解上述条规，

并保证一定遵循及执行之。本人宣誓没有刑事犯罪记录及没有涉及毒品罪案，本人也完全理解 CP 成员没有警察权力。

2. Saya juga berjanji memulangkan segala peralatan dan pakaian sekiranya saya dipecat keahlian, dan saya tidak

akan buat apa-apa tuntutan terhadap mana-mana individu atau ahli Community Policing, atau mana-mana

individu yang terlibat secara langsung atau tidak langsung dengan Persatuan Kepolisan Komuniti Malaysia. 一旦 CP 成员资格被开除，本人承诺必须归还所有属于人民社警的衣服、产品及用具，同时本人不会向任何人、或其他成员、

或任何与马来西亚人民社警总会有直接或间接关系的人士，作出任何索赔。

_________________________________________________ Tarikh 日期 : ___________________

Tandatangan Ahli Sukarelawan Community Policing 签名

Dengan kerjasama Supported by

支援单位

1. Nama Penuh mengikut Kad Pengenalan / Full Name of Insured as in NRIC / 姓名**

2. No. Kad Pengenalan Baru / New I/C No. / 身份证号码** 3. Tarikh Lahir / Date of Birth / 出生日期

- - - -

4. Umur / Age / 年龄** (Age limit entry16 - 60years)

5. Jantina / Gender / 性别**

L / M / 男

P / F / 女

6. Pekerjaan / Occupation / 职业**

7. Alamat Semasa / Current Address / 现时住址**

8. No. Telefon Bimbit / Handphone No. / 手机号码** 9. Tempoh Diansuranskan / Period of Cover / 受保期限

- - - - -

10. Nama Penuh Pewaris / Beneficiary Name / 受益人姓名**

11. No. Kad Pengenalan Baru Pewaris / Beneficiary New I/C No. / 受益人身份证号码** 12. No. Telefon Bimbit / Handphone No. / 手机号码

- -

13. Hubungan dengan Penama Diinsuranskan / Relationship with Insured / 与投保人之关系 : ______________________________________

DECLARATION

I to the best of my knowledge hereby confirm that the statements contained in this form are true and correct and I have not concealed mis-represented

or mis-stated any material act.

I agree that the statements and declaration contained in this proposal form shall be the basis of the contract of insurance with the company and are

deemed to be incorporated in the contract.

_____________________________________ Tandatangan / Signature of Insured / 投保人签名

_____________________ Tarikh / Date / 日期

** SOS Bantuan Komuniti/SOS Community Assistance/SOS 社区援助服务 RM53

BORANG INSURANS KEMALANGAN DIRI

PERSONAL ACCIDENT INSURANCE FORM

个人意外保险申请表格

Submitted by: Co chop & Initial

PERSONAL ACCIDENT INSURANCE

THE INSURER Berjaya-Sompo Insurance Berhad

THE INSURED

Any Eligible Members declared to FERG by Community Policing Malaysia

TABLE OF BENEFITS Benefit A DEATH occurring within twelve (12) calendar months of bodily injury as aforesaid. (Sum Insured = RM30,000.00)

Benefit B

PERMANENT DISABLEMENT occurring within twelve (12) calendar months of bodily injury as aforesaid. The percentages are as stated under Benefit B Coverage. (Sum Insured = RM30,000.00)

OTHER BENEFITS Burial or Cremation Allowance of RM2,000.00 shall be payable to the Insured’s next-of-kin or legal personal representative in the event of Benefit A is payable.

In the event of Death, Repatriation Expenses of up to RM5,000.00 shall be payable to reimburse the actual necessary and reasonable expenses incurred for the transportation of the mortal remains from the place where such death occur to the first point of entry into country of residence.

EXCLUSIONS This Policy does not cover: 1. Death or Disablement or any other loss caused directly or indirectly by:

a. War, invasion, act of foreign enemies hostilities or war-like operations (whether war be declared or not), civil war, rebellion, revolution, riot strike civil commotion, or any act of terrorism, insurrection, military or usurped power, or confiscation or nationalization or requisition or destruction of or damage to property by or under the order of any government or public of local authority.

For the purpose of this exclusion an act of terrorism means an act including but not limited to the use of force or violence and/or the threat thereof of any person or group(s) of persons whether acting alone or on behalf of or in connection with any organization(s) or government(s) committed for political religious ideological or similar purposes including the intention to influence any government and/or to put the public or any section of the public in fear.

This exclusion also excludes any liability loss damage cost or expense of whatsoever nature directly or indirectly caused by resulting from or in connection with any action taken in controlling preventing suppressing or in any way relating to (1a) above.

If the Company alleges that by reason of this exclusion any liability loss damage cost or expense is not covered by this insurance the burden of proving the contrary shall be upon the Life Insured. In the event any portion of this exclusion is found to be invalid or unenforceable the remainder shall remain in full force and effect.

b. Insanity suicide (whether sane or insane) or any attempt thereat. c. Pre-existing physical or mental defect or infirmity. d. Bacterial or viral infections any disease or sickness medical or surgical treatment (except such as may be necessitated solel y by injuries covered by

this policy and performed within the time provided in the policy). e. HIV (Human Immunodeficiency Virus) and/or HIV-related illnesses including AIDS and/or any mutant derivatives or variations thereof. f. Childbirth miscarriage pregnancy or any complications thereof. g. Any bodily injury which shall result in hernia.

2. Death or Disablement or any other loss sustained by the Life Insured: a. While riding or pillion riding on a two-wheeled motor vehicle as a sport. b. While using wood-working machinery driven by mechanical power except portable tools applied by hand and used solely for private without reward. c. While flying or engaging in other aerial activity except as a fare-paying passenger in an aircraft licensed for passenger services (the word “passenger”

does not include any member of the aircrew or any person involved in any technical operation or navigation in or upon an aircraft). d. While committing or attempting to commit any unlawful act.

3. Death or Disablement or any loss consequent upon the Life Insured engaging in or taking part in: a. Sports as a professional. b. Racing of any kind (other than on foot). c. Caving, parachuting, hang gliding, hunting, mountaineering requiring ropes or guides, waterski jumping, underwater activities involving the use of

breathing apparatus.

4. Death or Disablement directly or indirectly caused by or contributed to by or arising from: a. Ionizing, radiation or contamination by radioactivity from any nuclear waste from the combustion of nuclear fuel. For the pur pose of this exception,

combustion shall include any self-sustaining process of nuclear fission. b. Nuclear weapons material.

LIST OF EXCLUDED OCCUPATIONS 1. Acrobat or any Circus Worker 2. Airline Personnel and Aircrew 3. Animal Trainer 4. Explosive Handler 5. Detective Police Force or Private Investigator 6. Diver, Stevedore, and Workers on Oil Rig 7. Fireman 8. Horse Trainer and/or Jockey 9. Motor Racing of any kind 10. Naval, Military, or Air Force Servicemen or Operations

13. Persons working in Acid / Chemical Factories 14. Railway Manual Workers 15. Security Guard or Bodyguard 16. Ship Crews including Fishermen 17. Steeplejack 18. The use or handling of Nuclear and Radioactive Materials 19. Underground Tunneling and Mining Workers 20. Window Cleaner (more than 3-storey building) 21. Woodworking Machinist

11. Professional Athletes and Entertainers including Musicians and those engaged in the Theatrical profession 12. Sawyer, Timber Logging Workers, Drivers and/or Attendants of Timber Lorries and Winches