PSMB/INBASE/1/16

INDUSTRIAL BASED CERTIFICATION PROGRAMME (INBASE)

FOR INDUSTRY 4.0

APPLICATION FORM

TYPE OF TRAINEE

In- Service Future Workers

Employee
Please tick (√) where applicable

SUPPORTING DOCUMENTS TO BE ATTACHED

In- Service:
Copy of MyID (Identity Card)

Copy of Latest 1 Month Pay Slip

Future Workers:
Copy of MyID (Identity Card)

Highest academic qualification/latest academic transcript

Please tick (√) where applicable

A. TRAINING INFORMATION

1 Course Title :

2 Start Date :

3 Completion Date :

4 Venue :

1
5 Employer :
Association/ Training
Provider

B) TRAINEE INFORMATION

1 Name :

2 MyID Card No. : - -

3 Gender : Male Female

4 Race : Malay Chinese Indian Others. Please specify_______

5 Address :

Postcode State:

6 Tel. No (Office) :

7 Tel. No (Handphone) :

8 Email :

9 Social Media : LinkedIn : ……………………………………………………..

Preference (please
Facebook : ……………………………………………………..
provide ID)
Others : ………………………………………………………….
10 Academic : Sijil Pelajaran Malaysia (SPM)
Qualification
Sijil Tinggi Pelajaran Malaysia (STPM)

Certificate / Skills Certificate

Diploma

Bachelor Degree

Master Degree

2
 Doctoral Degree

Others: ………………………………………

11 Specify Highest :
Academic
Qualification;
eg. Bachelor of Economics

12 Designation : Manager Professional Technicians & Associate

* applicable only for
Clerical Support Workers Service and Sales Workers
in-service employees)

Skilled Agricultural, Forestry & Fishery Workers

Craft and Related Trades Elementary Occupations

Plant and Machine – Operators and Assemblers

13 Current Position :
*applicable only for in-
service employees)

14 Current Monthly : Below RM800 for Sabah and Sarawak

Salary Range Below RM900 for Peninsular Malaysia
*applicable only for in- RM800 to RM1,999 for Sabah & Sarawak
service employees)
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

None

3
(C) EMPLOYER INFORMATION (* applicable only for in-service employees)

1 Name of Current :
Employer

2 MyCoID (Company :
Registration Number) -
Compulsory
3 Industry : Manufacturing Service Agriculture

Construction Mining & Quarrying

Specify Sub sector:

4 Address :

Poscode State

5 Tel. No (Office) :

6 Fax . No. :

7 Contact Person (HR) :

8 HR Email Address :

D. EMPLOYER ENDORSEMENT (* applicable only for in-service employees)

I hereby declare that the above mentioned trainee is an employee of our company

Signature : ...........................................… Company Stamp:

Name : ……………………………..
Designation : ……………………………..
Date : ……………………………….

4
E. EMPLOYEE ENDORSEMENT

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.

Signature : ...........................................…………………………………….

Name : …………………………………………………………………

MyID Card No. : ………………………………………………………………….

Date : ……………………………………………………………….....