Lembaga Pembangunan Industri Pembinaan MalaysiaCONSTRUCTION INDUSTRY DEVELOPMENT BOARD Ibu Pejabat CIDB, Tingkat 7, Grand Seasons Avenue, No 72, Jalan Pahang, 53000 Kuala Lumpur Tel 03 2617 0200, Faks: 03 4043 0801 UPP 1 Pin.2/2008 FORM IS GIVEN FOR FREE PHOTO Please paste one recent i.c. size colour photograph with glue. Do not use stapler/cut the photo. PHOTO MUST BE SHARP & CLEAN CONSTRUCTION PERSONNEL REGISTRATION FORM The Construction Personnel Registration Programme is based to Pekeliling Program Kad Hijau CIDB Bil.1/2000 dan Bil.1/2001. General instruction: - This Form is to be read together with Construction Personnel Registration Requirements & Procedures. http:/www.cidb.gov.my NEW REGISTRATION RENEWAL Please √ where applicable. For renewal, information for A, F & G are necessary to fill-up. Please enclose the certified documents as instructed. A. APPLICANT'S INFORMATION (Enclose copy of certified i.c) Full name: (With capital letter as in i.c/passport) New i.c. no: CIDB Registration Card No: Date of birth: Old i.c. no: Nationality: EXTRA INFORMATIONS TO BE FILLED-UP BY FOREIGN WORKER Passport no: Work permit expiry date: Race: Sex: Male Female Marital status: Religion: Single Married Divorcee/Widow/Widower (Enclose copy of passport with valid work permit certified by employer as appear on work permit) Correspondence address: Permanent address if different: Postcode Tel. no.: Primary SRP/LCE /PMR Construction Worker Mobile tel. no.: SPM /MCE Skilled Construction Worker Postcode B. ACADEMIC/SKILL QUALIFICATION C. INFORMATION OF OCCUPATION General Worker (Enclose copy of Technical Cerificate (marked **) if any) Polytechnic** Diploma** SKM**/ Degree** SPVM** Construction Site Supervisor Assistant Construction Manager 30-39 500-749 Construction Site Manager Construction Trainee Others (please specify) Master** Degree Administrative Personnel Doctor of ** Phylosophy Others (please specify) Income in daily/monthly: daily monthly Amount of salary in RM: Daily <29 Monthly <499 40-49 750-999 50-59 1000-1499 60-79 1500-1999 80-99 2000-2499 100-1119 2500-2999 120-139 3000-3999 140 or 4000 more Field of skills & years of experience (please refer list of trades in the form) 1. 4. Years Years Please √ jif self employed 2. 5. Years Years Contractor registration no. with CIDB: 3. 6. Years Years D. EMPLOYER INFORMATION Company name and address: Tel no: Mobile tel no: Fax no: Postcode E. BENEFICIARY INFORMATION (Fill-up if applicant ages between 16 and 65 years old) Name: Sex: Male Relationship: Tel. no: Permanent address if different than applicant's address: Female I.c. no./ Birth cert. /passport (if available) F. APPLICANT'S DECLARATION I hereby certify that all the informations given and copy/ies of document/s enclosed with this form are right and true. Application/Registration will be automatically deemed nullified for any false information and action including lawsuit can be taken. G. CERTIFICATION (Certification can be made by officers as stated in the registration procedure. For foreign worker, certification can only be done by employer as appeared in the work permit). I hereby certiffy that informations given are true. CERTIFICATION Signature & Date Signature & Date Postcode Name Name REGISTRATION FEE Local worker Foreign worker with one year or less work permit Foreign worker with more than one year work permit RENEWAL FEE Local worker ages between 16 and 65 years Local worker ages above 65 years Foreign worker with one year or less work permit Foreign worker with more than one year work permit Tarikh terima: ........…........................... Bayaran: RM ................................ No. Resit: .................................................................................... RM50 RM25 RM50 RM50 RM50 RM70 RM100 RM50 RM25 RM50 (2 YEARS) (3 YEARS) (5 YEARS) Borang Bermasalah Bayaran kurang/tiada Maklumat pewaris tidak diisi Salinan sijil .................................... tidak disertakan Tiada pengakuan pemohon Tiada pengesahan majikan Pengesyoran Kategori & Tred GW CW SW SS AM MG Pembaharuan Tukar Kategori Tukar Tred KIV OFFICE USE Salinan k.p. tiada Salinan pasport/permit tiada Permit kerja syarikat lain Permit kerja bukan binaan Gambar tiada/tidak sesuai (5 YEARS) (AS IN WORK PERMIT) (MAXIMUM OF 2 YEARS) Payment can be made by money order or bank draft made payable to CIDB Malaysia. Cash payment can only be accepted for submission at CIDB counter Lain-lain: LT AD Semakan Ke2: .................................................................