SULIT

Chief Government Security Office (KPKK 11 FORM)

Prime Minister Department
SERVICE PROVIDER Recent
passport size
photograph
PERSONAL PARTICULARS
(Fill in the form in BLOCK LETTERS using a BLACK PEN)
1. Current Position: ……………………………………………………………………………………………………………………………………………..................
2. Employer: ………………………………………………………………………………………………………………………………………………………………………..
3. Full Name: ……………………………………………………………………………………………………………………………………………………………………….
4. Name in Chinese Characters (If applicable) :……………………………………Telephone No :………………………………………………………..
5. Passport No: ……………………………………………………………………………………………………………………………………………………………………
6. Sex :……………………………………Date/Place of Birth :…………………………………………………………………………………………………………….
7. Nationality: ……………………………………………………………………………………………………………………………………………………………………..
8. Residential Address: ………………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………………………………..
9. Correspondence Address: (If applicable):
Address Date Started Until

10. Name of Spouse (If applicable): ……………………………………………………………………………………………………....................................

11. Identification No (NRIC): …..……………………………………………………………………………………………………………………………………………..
12. Address: ………………………………………………………………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………………………………………………………
13. Have you ever been convicted whether within or without Malaysia of any criminal offence under any written law
involving fraud or dishonesty? If Yes, please state the offence(s): ……………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………
14. I hereby declare that all particulars given in this application form are to the best of my knowledge and belief true and
correct. I understand that any misleading, willful omission and falsification or incorrect statement of fact may lead to the
withdrawal of employment, or dismissal where employment has already commenced.

Date: ……………………………………………… …………………………………………………

(Signature of Applicant)
15. Employer Acknowledgement
I hereby acknowledge that the above named is employed by our company.
Date: ………………………………………………
Name: ……………………………………………...
Position: ………………………………………….. …………………………………………………
(Signature & Official Stamp)

SULIT
 GUIDELINES FOR FILLING UP FORM (KPKK 11)

1. Fill in the form (KPKK 11) in BLOCK LETTERS using a BLACK PEN.

2. Two (2) copies of passport-sized coloured photograph.

3. This form must be accompanied by approval/relevent authorities letter.

4. While filling in the form, please pay attention to ensure all sections has been filled in. Only the completed

form received will be processed and please address your application to:

PEJABAT KETUA PEGAWAI KESELAMATAN

KERAJAAN MALAYSIA

JABATAN PERDANA MENTERI

ARAS -1, 1 & 2, BLOK B7

PUSAT PENTADBIRAN KERAJAAN PERSEKUTUAN

62502 WILAYAH PERSEKUTUAN PUTRAJAYA

Tel No. : 03-8872 6012 / 6021

Fax No. : 03-8888 3270