Kursus yang ditawarkan : Pegawai Keselamatan dan
Kesihatan (SHO)
•Tarikh : 01-30/11/2016
•Tempoh : 22 hari
•Yuran kursus : Pembiayaan sepenuhnya oleh1 MALAYSIAGRIP*
•Syarat kelayakan
•< 2000 - SPM Gred 3 atau
•> 2000 - Minimum SPM kredit6C B.Melayu, B.Inggeris, Matematik Lulus 8E Sains dan 2 Matapelajaran lain atau
•Diploma keatas dan
•Majikan perlu berdaftar dengan PSMB dan
•Pekerja perlu mendapatkan kelulusanmajikan
•Kumpulan sasaran
•Pekerja warganegara Malaysia yang ingin meningkatkan taraf pendidikan
•Mempunyai pengalaman dalam pengurusan Projek
•Permohonan adalah berpandukankelulusan dari pihak PSMB
1 MALAYSIA GLOBALLY RECOGNISED INDUSTRY AND
PROPFESIONAL CERTIFICATION
(1 MALAYSIAGRIP)
Permohonan kursusNIOSH dan PSMB
•Borang yang dilampirkan perludiisi dan diserahkan
Semakan Kelulusan PSMB
•Pihak NIOSH akan membuat semakan untuk kelayakan
Menghadiri kursus
•Menghadiri kursus22 hari setelahmendapatkelulusan
Pendaftaran Peperiksaan SHO
•Mendaftar peperiksaan setelah tamat kursus
Bengkel
•Perlu menghadiri Kursus bengkel sebelum peperiksaan
Menduduki peperiksaan
•Perlu menjawab 4 kertas ujian
Sebarang Pertanyaan boleh menghubungi kami di:
Tel : 03 – 8911 3973/3974
Email :[email protected]
Website : www.niosh.com.my
Dokumen yang
diperlukan
Salinan Mykad,
salinan slip gaji
terkini, dan salinan
sijil akademikNIOSH PSMB
INSTITUT KESELAMATAN DAN KESIHATAN PEKERJAAN NEGARANATIONAL INSTITUTE OF OCCUPATIONAL SAFETY AND HEALTH (243042-U)
BORANG PERMOHONAN KURSUSCOURSE APPLICATION FORM
TEL : 03 - 8911 3800 FAX : 03 - 8926 3900 URL : www.niosh.com.my
NIOSH-A46P31-T Rev 6
TAJUK KURSUS COURSE TITLE TARIKH KURSUS COURSE DATE
A. MAKLUMAT PEMOHON APPLICANT’S INFORMATION
B. MAKLUMAT PENAJAAN SPONSOR’S INFORMATION
NAMA NAME
NAMA DI ATAS KADHOLDER NAME
MYKAD/ PASPORTMYKAD/ PASSPORT
ALAMAT SURAT-MENYURATMAILING ADDRESS
JANTINA GENDER
BANDARCITY
PEREMPUANFEMALE
LELAKIMALE
KELAYAKAN TERTINGGIHIGHEST QUALIFICATION
SPM/ MCE SPMV DIPLOMA
IJAZAH SARJANA MASTER’S DEGREE
DOKTOR FALSAFAH (PhD)DOCTOR of PHILOSOPHY (PhD)
IJAZAH SARJANA MUDABACHELOR’S DEGREE
UMURAGE
NAMA NAME
LAIN-LAIN, NYATAKANOTHERS, PLEASE SPECIFY
TAJAAN SENDIRISELF-SPONSORED
TAJAAN SYARIKATCOMPANY SPONSOREDPENAJA SPONSOR
BIDANG PENGAJIANFIELD OF STUDY
IMMEDIATE FAMILYWARIS TERDEKAT
EMERGENCY CONTACT NO.NO UNTUK DIHUBUNGI
RELATIONHUBUNGAN
E-MELE-MAIL
JAWATAN SEMASACURRENT POSITION
POSKODPOSTCODE
NEGERISTATE
ALAMAT SURAT-MENYURATMAILING ADDRESS
BANDARCITY
POSKODPOSTCODE
NEGERISTATE
NO. TELEFON TELEPHONE NO.
NO. FAKSIMILI FACSIMILE NO.
NO. TEL. BIMBIT HANDPHONE NO.
NO. TELEFON TELEPHONE NO.
PEGAWAI BERTUGASPERSON IN-CHARGE
JAWATANDESIGNATION
TARIKH LAHIRDATE of BIRTH
JENIS INDUSTRI (PILIH SALAH SATU)TYPE OF INDUSTRY (TICK ONE)
PEMBUATANMANUFACTURING
PERLOMBONGAN & KUARIMINING & QUARRYING
C. MAKLUMAT KEAHLIAN MEMBERSHIP INFORMATION
D. MAKLUMAT PEMBAYARAN PAYMENT INFORMATION
D. PENTING IMPORTANT
SILA HANTARKAN BORANG PERMOHONAN YANG TELAH LENGKAP KEPADA :PLEASE SEND COMPLETE APPLICATION FORM TO :
KEAHLIAN NIOSHNIOSH MEMBERSHIP
NO. KEAHLIANMEMBERSHIP NO.
YAYES
TIDAKNO
PERSEORANGANINDIVIDUAL
JIKA YAIF YES
KORPORATCORPORATE
KAEDAH PEMBAYARANPAYMENT METHOD
TUNAICASH
KIRIMAN WANGMONEY ORDER
DRAF BANKBANK DRAFT
PESANAN KERAJAAN (LO)LOCAL ORDER (LO)
BAYARAN SECARA ONLINE (MAYBANK2U)ONLINE PAYMENT (MAYBANK2U)
KAD KREDITCREDIT CARD
CEKCHEQUE
TANDATANGANPEMOHONAPPLICANT’S SIGNATURE
HARGA KURSUSCOURSE FEE
PERKHIDMATAN AWAM & PENGUATKUASAANPUBLIC SERVICE & AUTHORITY
PEMBINAANCONSTRUCTION
PEMBORONG & PERUNCITANWHOLESALE & RETAIL TRADE
HOTEL & RESTORANHOTEL & RESTAURANT
PERTANIAN, PERHUTANAN & PERIKANANAGRICULTURE, FORESTRY & AQUACULTURE
KEWANGAN, INSURAN, HARTANAH & PERKHIDMATAN PERNIAGAANFINANCE, INSURANCE, REAL ESTATES & BUSINESS SERVICE
UTILITI (ELEKTRIK, GAS, AIR & PERKHIDMATAN PENJAGAAN KEBERSIHAN)UTILITIES (ELECTRICITY, GAS, WATER & SANITARY SERVICE)
LAIN-LAIN : NYATAKANOTHERS : SPECIFY
PENGANGKUTAN, GUDANG & KOMUNIKASI TRANSPORTATION, WAREHOUSE & COMMUNICATION
COP RASMI SYARIKATCOMPANY OFFICAL STAMP
TANDATANGANSIGNATURE
TARIKHDATE
Ibu Pejabat NIOSH, (Selangor)
Faks : 03 - 8926 3900 (HETD)Tel : 03 - 8911 3815/ 3819 (HETD)
E-mel : [email protected]
Pejabat Wilayah Selatan
Tel : 07 - 599 1200 (Johor) : 06 - 232 6855/ 66 (Melaka)Faks : 07 - 599 0200 (Johor) : 06 - 232 6805 (Melaka)E-mel : [email protected] : [email protected]
Pejabat Wilayah Utara (P.Pinang)
Tel : 04 - 380 1200Faks : 04 - 397 3977E-mel : [email protected]
Pejabat Wilayah Pantai Timur (Kemaman)
Tel : 09 - 859 9961/ 62Faks : 09 - 859 9960E-mel : [email protected]
Pejabat Wilayah Sabah
Tel : 088 - 264 252 (Kota Kinabalu) : 087 - 423 254/ 408 778 (Labuan)Faks : 088 - 263 252 (Kota Kinabalu) :087 - 423 255 (Labuan)E-mel : [email protected]
NO. CEKCHEQUE NO.
TARIKH KEAHLIANDATE OF MEMBERSHIP
00.MR
TARIKHDATE
1. Sila pastikan cek dibayar atas nama “NIOSH”. No. akaun NIOSH : 5122 6840 2410 (Maybank, Cawangan Bandar Baru Bangi). Please ensure that cheque is payable to “NIOSH” . NIOSH account no : 5122 6840 2410 (Maybank, Bandar Baru Bangi Branch).
2. Jangan hantarkan wang tunai menerusi pos. Do not send cash through mail.
3. NIOSH berhak untuk menolak permohonan yang tidak lengkap. NIOSH has the right to reject incomplete application.
Pejabat Wilayah Sarawak
Tel : 086 - 311 500/ 330 600 (Bintulu) : 082 - 256 500/ 241 800 (Kuching) : 085 - 406 085/ 071 (Miri)Faks : 086 - 315 501 (Bintulu) : 082 - 253 020 (Kuching) : 085 - 406 086 (Miri)E-mel : [email protected]
1
PSMB/GRIP/1/15
1MALAYSIA GLOBALLY RECOGNISED INDUSTRY AND PROFESSIONAL
CERTIFICATION
(1MALAYSIAGRIP)
Employee of HRDF Registered Employer
Employee of Non Registered Employer with HRDF
Please tick (√) where applicable
Please tick (√)
1 Course Title :
2 Start Date :
3 Completion Date :
4 Venue :
5 Training Provider :
Copy of MyID (Identity Card)
Copy of Latest 1 Month Pay Slip
A. TRAINING INFORMATION
APPLICATION FORM
CATEGORY OF EMPLOYEE
SUPPORTING DOCUMENTS TO BE ATTACHED
2
1 Name :
2 MyID Card No. :
3 Gender : Male Female
4 Address :
Postcode State:
5 Tel. No (Office) :
6 Tel. No (Handphone) :
7 Email :
8 Social Media
Preference (please
provide ID)
: LinkedIn : ……………………………………………………..
Facebook : ……………………………………………………..
Others : …………………………………………………………..
9 Academic
Qualification
: Sijil Pelajaran Malaysia (SPM)
Sijil Tinggi Pelajaran Malaysia (STPM)
Certificate / Skills Certificate
Diploma
Bachelor Degree
Master Degree
Doctoral Degree
Others: ………………………………………
10 Specify Highest
Academic
Qualification;
eg. Bachelor of Economics
:
- -
B) TRAINEE INFORMATION
3
11 Current Position : Manager Professional Technicians & Associate
Clerical Support Workers Service and Sales Workers
Skilled Agricultural, Forestry & Fishery Workers
Craft and Related Trades Elementary Occupations
Plant and Machine – Operators and Assemblers
12 Exact Position :
13 Current Monthly
Salary Range
: Below RM800 for Sabah and Sarawak
Below RM900 for Peninsular Malaysia
RM800 to RM1,999 for Sabah & Sarawak RM900 to RM1,999 for Sabah & Sarawak RM900 to RM1,999 Peninsular Malaysia
RM2,000 to RM3,999 RM4,000 to RM5,999 RM6,000 to RM7,999 RM8,000 to RM9,999
RM10,000 and above
1 Name of Employer :
2 MyCoID (Company
Registration Number)
- Compulsory
:
3 Industry : Manufacturing Service Agriculture
Construction Mining & Quarrying
Specify Sub sector:
4 Address :
Poscode State
(C) EMPLOYER INFORMATION
4
5 Tel. No (Office) :
6 Fax . No. :
7 Contact Person (HR) :
8 HR Email Address :
Signature : ...........................................…….. Company Stamp:
Name : ……………………………………….
Position : ………………………………………..
Date : ………………………………….......
Signature : ...........................................………………………………
Name : …………………………………………………………………
MyID Card No. : …………………………………………………………………
Date : ………………………………………………………………...
I hereby declare that the above mentioned trainee is an employee of our company
I declare that the facts stated in this application and the accompanying information are true and correct and
I have not withheld / distorted any material fact.
D. EMPLOYER ENDORSEMENT
E. EMPLOYEE ENDORSEMENT