LAMPIRAN A HENDAKLAH DIKEMBARKAN BERSAMA BORANG POLIS 128 PIN. 3/88 NAMA PEMOHON: TARIKH LAIR: UMUR: TAHUN NO. K/P BARU: PEKERJAAN:

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1 LAMPIRAN A HENDAKLAH DIKEMBARKAN BERSAMA BORANG POLIS 128 PIN. 3/88 NAMA PEMOHON: TARIKH LAIR: UMUR: TAHUN NO. K/P BARU: LAMA: PEKERJAAN: BIL SOALAN JAWAPAN 1. Yang telah lalu, adakah lesen senjata api tuan telah ditarik atau dibatalkan? 2. Adakah tuan menjadi anggota di dalam sebarang pertubuhan? 3. Pernahkah tuan berkhidmat dalam Pasukan Rela, Polis DiRaja Persekutuan, Kawalan Kampung, Tentera atau sebarang Pasukan Bersenjata? Jika ada, nyatakan nombornya sekali. 4. Pernahkah tuan dihukum dalam sebarang Mahkamah di Persekutuan Tanah Melayu atau kesalahan jenayah? 5. Adakah saudara tuan atau orang-orang di dalam rumah tuan ada memiliki senjata api yang berlesen. (Jika ada berikan no. Lesen dan tujuan memiliki senjata api berkenaan. 6. Sekiranya senjata api yang dikehendaki itu untuk menjaga keselamatan diri tuan, nyatakan sebab-sebab yang tuan mustahak memiliki senjata api. 7. Adakah tuan menghidap penyakit seperti hilang akal, gila babi, pitam dan lemah jantung atau lain-lain penyakit? 8. Yang telah lalu, adakah tuan memiliki senjata api yang berlesen. Sekiranya ada, apa yang telah terjadi kepada senjata api tersebut? 9. Adakah tuan berpengalaman menggunakan senjata api yang tuan kehendaki itu. 10. Apakah yang mewajibkan tuan hendak senjata api itu? Kiranya permohonan tuan diluluskan, apakah langkah yang tuan lakukan untuk menjaga keselamatan senjata api tersebut

2 BAHAGIAN II 1.1 Bahawa sesungguhnya saya mengaku, saya atau suami/isteri* saya atau ibu bapa saya atau adik beradik saya atau anak-anak saya tidak pernah dihukum sabit/kesalahan jenayah atau ditahan oleh Polis atau lain-lain pihak berkuasa kerana sesuatu sebab. I declare that neither nor my spouse, nor my parents or brothers/sister or children, have been convicted of any offence or detained by the Police or any other authority for any purpose 1.2 Dan saya mengaku sepanjang pengetahuan dan pendapat saya keterangan-keterangan yang diberi di atas ini adalah benar. And I declare that to the best of my knowledge and belief the details given above are true Tarikh: ( ) Tandatangan Pemohon

3 PERMOHONAN UNTUK LESEN BERNIAGA/LESEN MEMBAIKI/ CANTUMAN LESEN BERNIAGA DAN MEMBAIKI 1. BORANG POL BORANG POL BUTIR PENGALAMAN DALAM PENGENDALIAN SENJATAPI DAN AMUNISASI KEMBARKAN SIJIL/SURAT PENGESAHAN. 4. SESALINAN BUSINESS MEMORANDUM AND ARTICLE OF ASSOCIATION 5. KESESUAIAN TEMPAT PERNIAGAAN 6. BILIK KEBAL/TEMPAT SENJATAPI (GAMBAR-GAMBAR) 7. LANGKAHAN PENCEGAHAN KEBAKARAN 8. SISTEM AMARAN KESELAMATAN 9. PELAN SUSUR ATUR/ PERMIS PERNIAGAAN YANG DICADANGKAN 10. LAIN-LAIN BUTIR BERKAITAN YANG BOLEH MENYOKONG PERMOHONAN TERSEBUT KEPING GAMBAR BERUKURAN PASSPORT 12. SESALINAN KAD PENGENALAN

4 LESEN BERNIAGA SENJATAPI BAGI TUJUAN UJIKAJI 1. Borang POL Borang POL Business Memorandum And Article 4. Surat Kementerian Kewangan (Tajuk Kepala) 5. End User Certificate 6. Form Salinan Kad Pengenalan 8. Lokasi Pejabat 9. Gambar Berukuran Pasport 10. Tentera/Polis: Salinan Surat Berhenti Kerja

5 PERMOHONAN MEMBELI ATAU PINDAH MILIK SENJATAPI SHOTGUN BAGI TUJUAN MENCEGAH MUSUH TANAMAN Si Pemohon dihendaki mengemukakan borang Polis 128 yang telah dipenuhkan kepada Ketua Polis Daerah bersama-sama dengan salinan fotostat / maklumat atas perkara-perkara berikut: 1) Salinan semua geran tanah pertanian yang dimiliki oleh pemohon 2) Salinan geran tanah pertanian yang ada kaitan dengan permohonannya umpamanya tanah isteri / adik-beradik / ibu bapa yang perlu dijaga oleh pemohon: 3) Surat menerangkan seperti berikut: 3a) Jenis dan umur tanaman yang terdapat di atas tanah-tanah itu 3b) Jenis musuh yang sering mengganggu tanaman-tanaman tersebut 3c) Jarak jauh antara rumah si pemohon dengan tanah-tanah yang berkenaan 3d) Hingga kini bagaimanakah tanaman-tanaman di atas tanah-tanah itu dijagakan 3e) Taksiran hasil yang diperoleh dari tanaman-tanaman ini dan taksiran kerugian yang disebabkan oleh musuh-musuh 4) Surat pengakuan dari pemohon mengesahkan bahawa dia sanggup meminjamkan Shotgunnya kepada Pasukan Rela apabila perlu. 5) Kiranya pemohon adalah seorang Ahli Rela, sertakan surat pengesahan dari Pegawai Rela tempatan. 6) Nyatakan lain-lain sebab pemohon memerlukan senjata api Shotgun 7) 3 keping gambar berukuran Pasport. 8) Surat keizinan dari tuan punya senjata api (Jika ditukar milik C/U) 9) Laporan dari Pegawai Pertanian 10) Salinan Kad Pengenalan 11) Surat keizinan penjagaan tanah dari tuan punya tanah, jika tanah bukan nama pemohon

6 PERMOHONAN MEMBELI ATAU PINDAH MILIK SENJATAPI PISTAL / REVOLVER / SHORTGUN /BAGI TUJUAN A) Menjaga keselamatan diri B) Menjaga keselamatan Harta Benda Syarikat Si pemohon dihendaki mengemukakan borang Polis 128 yang telah dipenuhi kepada Ketua Polis Daerah bersama-sama dengan salinan fotostat / maklumat atas perkaraperkara berikut:- 1) Business Memorandum bagi semua Syarikat kepunyaan tuan atau yang tuan menjadi Pengerusi/ Pengarah. 2) Sesalinan senarai pekerja-pekerja bagi semua syarikat tersebut yang mencarum kepada Kumpulan Wang Simpanan Pekerja (EPF). 3) Penyata Bank 3 bulan terakhir bagi Syarikat-Syarikat berkenaan 4) Taksiran cukai pendapatan (Borang J) 3 tahun kebelakangan bagi syarikat-syarikat berkenaan. 5) Penyata bank 3 bulan terakhir bagi permohonan sendiri 6) Taksiran cukai pendapatan (Borang J) 3 tahun kebelakangan permohonan sendiri. 7) Senarai nama Pengarah-Pengarah Syarikat tersebut yang sudah memiliki senjata api, sebutkan jenis dan tujuan senjata api itu dilesenkan. 8) Surat dari salah sebuah Syarikatnya mengesahkan sama ada pemohon dibuat di atas nama Syarikat atau persendirian 9) Kenyataan tentang tugas dan tanggungjawab pemohon dalam Syarikat tersebut dan sebab-sebab mengapa ia memerlukan senjata api. 10) Kenyataan sama ada pemohon telah diancam, diperas ugut atau diganggu oleh anasir-anasir jahat. Kepilkan salinan Laporan Polis jika ada. 11) Bagi tujuan menjaga keselamatan harta, senaraikan projek-projek binaan yang sedang dan akan dilaksanakan, gendong, kilang-kilang, lombong dan sebagainya juga lokasi harta-harta itu dan nilainya. 12) 3 keping gambar berukuran Pasport. 13) Surat keizinan dari tuan punya senjata api (Jika tukar milik C/U) 14) Salinan Kad Pengenalan

7 AGENSI KESELAMATAN 1) i) Nama Pemohon: ii) K/P: iii) Umur: iv) Jawatan dalam syarikat: v) Alamat tempat tinggal dan no. Telefon: 2) i) Nama syarikat: ii) Tarikh ditubuhkan iii) Nombor lesen: iv) Alamat Pejabat dan No. Telefon: v) Kedudukan kewangan syarikat: a) Penyata akaun bank untuk 3 bulan b) Bayaran cukai pendapatan tahunan c) Paid up capital syarikat vi) Senarai/alamat cawangan-cawangan syarikat: 3) Pekerja syarikat: i) Senarai/alamat cawangan-cawangan syarikat: ii) Bilangan pengawal: iii) Bilangan pengawal memiliki C & U: iv) Bilangan pekerja am pejabat: v) Penyata EPF pekerja:

8 4) Senjata api: i) Bilangan dan jenis senjata api sedia ada: ii) Bilangan dan jenis senjata api dipohon: iii) Tempat simpanan senjata api: Sedia ada / sedang dibina / dalam perancangan 5) Keperluan senjata api i) Senarai kontrak kawalan sedang berjalan: ii) Senarai tawaran kontrak baru ( x-ref. With folio ) iii) Nilai kontrak sedia ada sebulan: iv) Jangkaan nilai kontrak baru sebulan: v) Kemahiran pengawal menggunakan senjata api: a) Jumlah terlatih: b) Jumlah tanpa latihan: 6) Justifikasi jenis senjata api yang dipohon: 7) Justifikasi bilangan senjata api yang dipohon: 8) Tapisan Keselamatan: 9) Justifikasi perakuan oleh Ketua Polis:

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