SULIT

Chief Government Security Office

(KPKK 11 FORM)
Prime Minister Department

SERVICE PROVIDER
PERSONAL PARTICULARS
(Fill in the form in BLOCK LETTERS using a BLACK PEN)

Recent
passport
size
photograp
h

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