Form A (REGISTRATION OF ISLAMIC RELIGIOUS SCHOOLS (MALACCA) REGULATIONS 2003

M.P.U. 1/2003
REGISTRATION OF ISLAMIC RELIGIOUS SCHOOLS (MALACCA) REGULATIONS 2003

Form A

(Paragraph 3(1)(a))

APPLICATION FOR REGISTRATION OF ISLAMIC RELIGIOUS SCHOOL

Registrar
Islamic Religious Schools
Islamic Religious Department of Malacca
Malacca

Attached herewith are the details regarding an existing Islamic Religious School / which is proposed to be established (*) at the address stated and I am applying for this Religious School to be registered.

2. Also enclosed herewith is the fee for the application as follows:

Bank Draft No.: .............................................................................. Name of Bank:.................................................................................. Address of Bank: ..............................................................................

Yours faithfully,

..................................................
(Applicants’ Signature)

Full name: ........................................................................................ Identification Card No : ........................................................................ Designation: ..................................................................................... Date : .............................................................................................

* Delete whichever is inapplicable.

PART I

Please tick ( / ) in the relevant boxes. Delete (*) whichever is inapplicable.

A. DETAILS OF APPLICANT

1. Name of Applicant: ........................................................................
2. Status of Applicant:

3. Address: ............................................................................................................................................................................................... Postcode: ............... Telephone No: .............. Facsimile No: ............ E-Mail Address: ............................................

B. PARTICULARS OF ISLAMIC RELIGIOUS SCHOOL

1. Name of Islamic Religious School: ....................................................................................................................................................................................................

2. Address: ................................................................................................................................................. Postcode: .................................... Telephone No: ..........................Facsimile No: .............................. E-Mail Address : .........................................................................

3. Status of Site Building:

(Please forward a copy of the land title which has been certified)

4. Type of Institution:

5. Medium of Instruction:

6. Curriculum (Please forward a copy of the proposed curriculum except if KBSR, KBSM or curriculum of the Jabatan Agama Islam Melaka is used):

7. Type of Study:

8. Financing:

C. OWNERSHIP OF ISLAMIC RELIGIOUS SCHOOL

1. Owner:

2. If Government:

3. If private, please fill in the following detail:

4. If Wakaf, please get further information from the Lembaga Urusan Zakat dan Baitulmal (LUKMAL), Majlis Agama Islam Melaka:

— Type of Wakaf: ...................................................................

— Information on Wakaf: ..........................................................

— Status of Wakaf land (Please attach a copy of the land title)

5. If Individual, please state:

Name of Owner: ........................................................................ Identification Card No.: .............................................................. Registered Address of Owner:.......................................................................................................... Postcode:............................ Telephone No.:......................... Facsimile No.: ................................. E-Mail No.: .............................................................................. Registration No.: ...................................................................... Date of registration:..................................................................

(If the applicant is not the registered owner of the land,there shall be produced a letter of undertaking by the registered owner of the land stating that the land may be used for the purposes of the school and that the school may enjoy the use of the land free from disturbances to the said land for such period as may be specified).

D. INFORMATION REGARDING PREMISES AND FACILITIES

Please ensure that the following details are attached together:

(i) a certified copy of the plan of the whole building;

(ii) a certified copy of safety certificate issued by the Fire and Rescue Department;

(iii) a certified copy of health certificate issued by the Health Department; and

(iv) a certified copy of certificate of fitness of occupation issued by the Local Authority.

1. Information on Premises

2. Information on Ownership:

If tenancy, please state:

amount of rental: RM......................................... monthly /yearly*

date of commencement of term of tenancy: ...................................

date of expiry of term of tenancy:...................................................

name and address of owner of premise: ......................................................................................................................................... (Please attach a copy of the tenancy agreement)

3. Floor area of premise: ..............................................................

4. Site area of premise: .............................................................. (Please attach a copy of the site plan of premise)

5. Particulars on Building:

E. MANAGEMENT

1. Name of the Chairman of the Board of Management of the religious school as in Form C:

(a) Full name: .......................................................................

(b) Identification Card No. / Passport No.: ............................

(d) Profession: .........................................................................

(e) Academic qualifications: ........................................................

(f) Profesional qualifications: ...............................................

(g) Experience in the field of education: ..............................

(h) Experience in the field of management : ..............................

Please attach:

(i) curriculum vitae of the Chairman of the Board of Management

(ii) a certified copy of Certificate / Diploma / Degree

(iii) a certified copy of Identification Card/ Passport

2. Name, Identification Card No. and qualification of Principal/Head Teacher/Teachers as in Appendix 1:

(a) Full name: ............................................................................

(b) Identification Card No. / Passport: ..................................

(d) Profession: .....................................................................

(e) Academic qualification: .....................................................

(f) Professional qualification: .................................................

(g) Experience in the field of education: ...................................

(h) Experience in the field of management: ................................

Please attach:

(i) curriculum vitae of Principal / Headmaster/Teacher;

(ii) a certified copy of letter of appointment of Principal/Head Teacher/Teacher

(iii) a certified copy of Certificate/Diploma/Degree of Principal/Head Teacher/Teacher

(iv) a certified copy of Identification Card/Passport of Principal/Head Teacher/Teacher

(v) a certified copy of Teaching Permit of Principal/Head Teacher/Teacher

(vi) a certified copy of Credential Religious Teaching of Principal/Head Teacher/Teacher.

3. Information on financial sources as in Appendix 2:

(i) Registration fee : RM .......................

(ii) Monthly fee : RM .......................per month

(iii) Public donation : RM .......................per year

(iv) Others : RM .......................*per month/per year

F. DECLARATION OF APPLICANT

We do solemnly and sincerely declare that all statements contained in this application form and all documents attached herewith are true to the best of our knowledge and belief.

Signature of Chairman: ..................................... Date:............................

Name of Chairman: .........................................................................

Signature of Secretary: ................................. Date: ...........................

Name of Secretary: ................................................................................

Signature of Treasurer: ................................. Date: ...........................

Name of Treasurer : .......................................................................

PART II

FOR OFFICE USE ONLY

Appendix 1

LIST OF NAMES, IDENTIFICATION CARDS NO. AND QUALIFICATION OF PRINCIPAL/HEAD TEACHER/TEACHERS OF ISLAMIC RELIGIOUS SCHOOLS

Appendix 2

INFORMATION ON FINANCIAL SOURCES OF ISLAMIC RELIGIOUS SCHOOLS