THE PUBLIC SERVICES DEPARTMENT OF MALAYSIA THE PENSION DIVISION

1. Country code Old Old New New Military Military 04 04 Police Police 02 02 03 03 01 01 THE PUBLIC SERVICES DEPARTMENT OF MALAYSIA THE PENSION DIVISION JPA.BP.SPT.B03b DECLARATION OF STUDENT STUDYING IN THE INSTITUTION OF HIGHER LEARNING INSTRUCTIONFOR OFFICE USE ONLY 1. Please fill in this form by using BLACK/BLUE ink only. 2. Please use CAPITAL LETTERS. 3. Please tick √ in boxes with (*). Ref. No : Received Date : / / Day Year Month PARTICULARS OF DECEASED A 1a. Current identity card number 1b. Category of current identity card number * FOR OFFICE USE ONLY 2. Name of deceased STUDENT’S PARTICULARS B 1b. Category of current identity card number * 1a. Current identity card number 2. Name of student 3. Address 4. Postcode 5. City State code 6. State 7. Country 8. Telephone no. 9. Email address 10. Marital status * 11. Marriage date (if married) Single Married / / Day Month Year - 1 - IIIIIIII II IIII I I III BAHAGIAN PENCEN, JPA

2. Country code JPA.BP.SPT.B03b COURSE DETAILS ( to be filled by student ) C 1. Nameof institution FOR OFFICE USE ONLY 2. Institution full address 3. Postcode 4. City State code 5. State 6. Country 7. Telephone no. 8. Email address 9. Registration no. 10. Course 11. Faculty 12. Duration of Course 13. Date of registration (the first year entry into the institution of higher learning) Year / / Day Month Year 14. Date at which the course is expected to end (i.e. the last day of the final semester/quarter/term) 15. Present year of study (year 1, 2, etc) Year / / Day Month Year 16. Degree / Diploma that will be awarded (state in full) - 2 - IIIIIIII II IIII I I III BAHAGIAN PENCEN, JPA

3. STUDENT’S DECLARATION D JPA.BP.SPT.B03b I hereby declare that the above details are correct. FOR OFFICE USEONLY (Signature of student) Date : CERTIFICATION BY REGISTRAR OF THE INSTITUTION OF HIGHER LEARNING E I hereby certify that the details in section (B) and (C) are correct. (Signature of Registrar) Name : Position held : Date : Official seal of the Institution of Higher Learning : Checked by : Name : Position : Unit : Date : Verified by : Name : Position : Unit : Date : - 3 - IIIIIIII II IIII I I III BAHAGIAN PENCEN, JPA