JL/HEPP/B/01 Pin.1/99
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JABATAN LAUT SEMENANJUNG MALAYSIA
MARINE DEPARTMENT PENINSULAR MALAYSIA 		  Sertakan 3 Keping 
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BORANG PENDAFTARAN PELAUT
SEAFARER REGISTRATION FORM

 
Tandakan (/) pada permohonan yang berkenaan.
Tick (/) at the appropriate application.

    Pendaftaran Pelaut Tempatan           Pembaharuan Pendaftaran Pelaut Tempatan       Buku Perkhidmatan Pelaut        Kehilangan Buku Pe rkhidmatan Pelaut 
    Registration of Local Seafarer        Renewal Registration of Local Seafarer           Seafarer Discharge Book           Lost of Discharge Book 
 

     Kehilangan Buku Perkhidmatan Pelaut         Pendaftaran Pelaut Asing                                      Pembaharuan Pendaftaran Pelaut Asing 
     Regist ration of Foreign Seafarer                Renewal Registration of Foreign Seafarer              Lost of Seaman Card 
A. Maklumat Peribadi (Personal Particulars)
Nama : _____________________________________________ No. K/P Lama : ____________________________ No. K/P : ________________________
Name                                                                               Old NRIC                                                         New NRIC

No. Pasport : _________________________ Warganegara : ________________      Keturunan: _______________     Agama : _________________
Passport No                                             Nationality                                                Race                                       Religion

Alamat : ______________________________________________________________ Bandar & Negeri : _________________ 
Address                                                                                                                                                  City & State 

Poskod : __________________________ No. Tel : ________________________ (Rumah/House)/________________________ (Pejabat/Office) 
Postcode                                                              Tel. No. 

Warna Mata : ____________________ Warna Rambut : _______________ Tinggi : _________sm         Jantina :              Lelaki                  Perempuan
Colour of Eyes                                  Colour of Hair                            Height                  cm          Sex                    Male                    Female

Tanda di badan : _______________________________________    Tempat Lahir : _______________________     Tarikh Lahir : ___________________ 
Distinguishing Marks                                                                Place of Birth                                              Date of Birth 

Bahagian :                     Dek            Enjin             Sajian                    Lain-Lain             Pangkat Sekarang : _________________________________
Department                    Deck           Engine           Catering              Others                  Present Rank
 
B. Maklumat Waris (Particulars Next of Kin)
Nama : _______________________________________________ Pertalian : ______________________ No. K/P : ______________________
Name                                                                                  Relationship                                    NRIC No

Alamat :_____________________________________________________________________________________________________________________________________
Address

_____________________________       Bandar & Negeri : __________________________        Poskod :   __________________________
                                                       City & State                                                                                                      Postcode

No. Tel. : ________________________________ (Rumah/House)     ______________________________ (Pejabat/Office) 
Tel. No
 
C. Sijil Kecekapan (Certificate of Competency)
D. Rekod Perkhidmatan (Service Record)
Jika ada, sila lampirkan salinannya (If any, please attach the copy) Sila kemukakan salinan Buku Pelaut (Please enclose the copy of a Discharge Book)
E. Tempat Pungutan (Place of Collection)
       Datang Sendiri (Self Collection)                                 Melalui Pos. Sila nyatakan alamat jika berlainan dari di atas: ______________________________
       By post.                                                                  Please state if different from the above address:

F. Pengakuan (Declaration)

Saya dengan ini mengakui bahawa keterangan yang diberi adalah benar.
I hereby certify that the informations given are true.

Tarikh : ___________________________________________________________ Tandatangan Pemohon : ______________________________
Date                                                                                                          Applicant’s Signature
 
 
 
Untuk Kegunaan Pejabat ( For official use ) :

No. Kad Pelaut : __________________   No. Buku Pelaut :_______________ Pejabat Pelabuhan Yang Menerina Permohonan :_______________