AKTA INDUSTRI PERKHIDMATAN AIR 2006 WATER SERVICES INDUSTRY ACT 2006
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1 SPAN/QP/ AKTA INDUSTRI PERKHIDMATAN AIR 2006 WATER SERVICES INDUSTRY ACT 2006 BUTIRAN SEBAGAI ORANG YANG BERKELAYAKAN DI BAWAH SEKSYEN 47(7) AKTA IPA 2006 PARTICULARS AS A QUALIFIED PERSON UNDER SECTION 47(7) WSIA 2006 Kepada: Suruhanjaya Perkhidmatan Air Negara To: 1. Butir-butir peribadi Personal Particulars (a) Nama:.. No Kad Pengenalan / No Pasport (yang mana berkaitan):.. NRIC No / Passport No (whichever applicable): (d) Jawatan dalam firma, dll: Position in firm, etc.: Alamat- Address- (i) Perniagaan: Business.:... No. Telefon:.. No Faks:..... Telephone No: Faks No: Emel:. (ii) Tempat tinggal: Residence.: (f) (e) Warganegara:... Nationality.: Disiplin: (Arkitek/ Kej. Awam/ Kej. Mekanikal/Lain-lain (sila nyatakan): ) Discipline: (Architect/Civil Eng /Mechanical Eng/others (please specify) (g) Nombor Pendaftaran dengan Lembaga Jurutera Malaysia(LJM)/Lembaga Arkitek Malaysia (LAM): Registration No with Board of Engineers Malaysia(BEM)/Board of Architects Malaysia(BAM):.. Sila lampirkan suatu salinan yang diakui sah sijil pendaftaran yang dikeluarkan oleh LJM/LAM Please attach a certified true copy of the applicant s certificate of registration issued by the BEM/BAM (h) Maklumat lain (contoh: pendaftaran dengan badan professional lain):... Other information(e.g: registration with other professional bodies): 1/3
2 2. Butir-butir syarikat / Majikan Particulars of Company/Employer (a) Nama syarikat:.. Name of company: (d) (e) No. pendaftaran syarikat:. Company s registration No.: Alamat syarikat: Company s address: Nombor Pendaftaran Syarikat dengan LJM/LAM (sekiranya ada): Company Registration No with BEM/BAM(if any): Tahun ditubuhkan: Year of incorporation: 4. Butir-butir kelayakan dan pengalaman professional penama berkenaan (sila gunakan lampiran tambahan) Particulars of qualification and experience of individual concerned on water or other related field (use additional sheet) (a) Jumlah tahun pengalaman penama: Total years of experience of the individual: Pengalaman penama dalam perancangan, rekabentuk dan penyeliaan tapak dalam bidang air, pembetungan atau bidang lain yang berkaitan untuk diisi dalam jadual di bawah (sila guna lampiran tambahan). of individual in planning, designing and supervision of construction etc in water, sewerage or any related fields to be provided in the table below (please use additional sheet) No No. Nama dan Kos Projek Name and cost of project Pengalaman Berkaitan (dalam bidang air, pembetungan atau bidang berkaitan) Relevant (In water, sewerage or other related field) Skop Kerja yang dijalankan Scope of Works Tahun Year Saya... dengan ini: I hereby: (a) mengaku mengikut peruntukan-peruntukan Akta Akuan Berkanun 1960 bahawa semua maklumat yang diberikan di dalam borang ini adalah benar dan tepat; dan declare in accordance with the provisions of the Statutory Declaration Act 1960 that all the information given in this form is true and accurate; and memberikan persetujuan saya dan memberi kuasa kepada Suruhanjaya untuk akses dan mendapatkan semua maklumat daripada Lembaga Jurutera Malaysia dan Lembaga Arkitek Malaysia; dan grant my consent and authorise the Commission to access and obtain all such information from Board of Engineers Malaysia and Board of Architects Malaysia; and memberikan persetujuan selanjutnya untuk membenarkan Lembaga Jurutera Malaysia dan Lembaga Arkitek Malaysia untuk melepaskan maklumat dan dokumen kepada Suruhanjaya, iaitu maklumat dan dokumen yang juga dikehendaki oleh Lembaga Jurutera Malaysia dan Lembaga Arkitek Malaysia further consent to authorise the Board of Engineers Malaysia and Board of Architects Malaysia to release such information and document to the Commission, where the same is required by the Board of Engineer Malaysia and Board of Architect Malaysia. Nota: Professional penama yang berkenaan tidak perlu mengemukakan maklumat dan dokumen yang telah dikemukakan kepada Lembaga Jurutera Malaysia atau Lembaga Arkitek Malaysia secara fizikal dengan syarat bahawa Suruhanjaya diberikan akses dan mampu untuk mendapatkan maklumat dan dokumen tersebut secara terus dari Lembaga Jurutera Malaysia atau Lembaga Arkitek Malaysia. 2/3
3 Note: The professional concerned is not required to physically submit the information and documents submitted to the BEM or BAM provided that the Commission is granted access to and is able to obtain such information and document directly from the BEM or BAM. Tandatangan profesional penama yang berkenaan Signature of professional concerned Tarikh: Date 3/3
4 Lampiran A SPAN QP BUTIRAN ORANG YANG BERKELAYAKAN DI BAWAH SEKSYEN 47 AKTA IPA 2006 Total In Water & Scope (Planning /design /supervision In Water or ) Water Specialization Water Treatment Plant Tangki Septik Individu (Untuk satu unit rumah) Stesen Pam Rangkaian Water Distribution System Tangki Septik Individu (Untuk 30 unit rumah) Loji Rawatan Kumbahan Pumping System Sambungan ke paip pembetungan awam Kemudahan Rawatan Enapcemar Plumbing System Rangkaian Pembetungan Kerja-kerja naiktaraf loji rawatan kumbahan Company s Name & Address : IC : PE No: since: (date) Discipline : Tel /Fax/ Sign: Nota: Anda dikehendaki mengemukakan maklumat yang benar dan kegagalan berbuat demikian boleh menyebabkan tindakan undang undang dikenakan.
5 Contoh: Lampiran A SPAN QP Total In Water & Scope (Planning /design /supervision In Water or ) Water Specialization Cth: Water Treatment Plant Nil Tangki Septik Individu (Untuk satu unit rumah) 3 Stesen Pam Rangkaian Nil Design & Supervision In Water and Water Distribution System 2 Tangki Septik Individu (Untuk 30 unit rumah) Pumping System Nil Sambungan ke paip pembetungan awam 3 Loji Rawatan Kumbahan 1 3 Kemudahan Rawatan Nil Enapcemar Plumbing System 3 Rangkaian Pembetungan Nil Kerja-kerja naiktaraf loji rawatan kumbahan Nil Company s Name & Address : IC : PE No: since:(date) Discipline : Tel /Fax/ Sign:
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