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1. Profil Individu / Individual Profile 1.1 Maklumat Akaun / Account Information SHARIMAH BINTI AMILASAN 820326125932 [email protected] 01193705794 Malaysian 26-Mar-1982 30 1.2 Profil Peribadi / Personal Profile 1,764.84 NOTA : Jumlah Pendapatan Keluarga (RM/Bulan) mesti di dalam linkungan RM 2,500 - RM 7,500. Sila rujuk kepada Kriteria Kelayakan untuk definisi pendapatan purata kasar bulanan. NOTE : Total Household Income (RM/Month) must be within RM 2,500 - RM 7,500. / Please refer to Eligibility Criteria on definition of average monthly gross income. Tidak / No Tiada / None Pn / Mrs Perempuan / Female Bumiputra Sabah / Bumiputra Sabah Berkahwin / Married Ya / Yes Blok A3 T6 U8, Pangsapuri putra Harmoni, Presint 9 Putrajaya 62250 Wilayah Persekutuan Putrajaya Nama seperti di dalam IC / Name as stated in NRIC No. kad pengenalan (Baru) / NRIC (New) Emel / Email No. telefon bimbit / Mobile phone Warganegara / Nationality Tarikh lahir / D.O.B. Umur / Age Apakah pendapatan purata kasar bulanan anda? (RM/Bulan) / What is your monthly gross personal income? (RM/Month) Adakah anda pernah diisytiharkan muflis? / Have you been declared bankrupt? Pengenalan ID lain / Other ID type Gelaran / Title Jantina / Gender Bangsa / Race Taraf perkahwinan / Marital status Adakah anda mempunyai anak? / Do you have children? Alamat Rumah / Home Address Alamat baris 1 / Address line 1 Alamat baris 2 / Address line 2 Pekan atau bandar / Town or city Poskod / Postcode Negeri / State Telefon rumah / Home phone Pemilikan kediaman di atas / Ownership of above property

PR1MA_634918547671816805

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Page 1: PR1MA_634918547671816805

1. Profil Individu / Individual Profile

1.1 Maklumat Akaun / Account Information

SHARIMAH BINTI AMILASAN

820326125932

[email protected]

01193705794

Malaysian

26-Mar-1982

30

1.2 Profil Peribadi / Personal Profile

1,764.84

NOTA : Jumlah Pendapatan Keluarga (RM/Bulan) mesti di dalam linkungan RM 2,500 - RM 7,500. Sila rujuk kepada KriteriaKelayakan untuk definisi pendapatan purata kasar bulanan.NOTE : Total Household Income (RM/Month) must be within RM 2,500 - RM 7,500. / Please refer to Eligibility Criteria on definition ofaverage monthly gross income.

Tidak / No

Tiada / None

Pn / Mrs

Perempuan / Female

Bumiputra Sabah / Bumiputra Sabah

Berkahwin / Married

Ya / Yes

Blok A3 T6 U8, Pangsapuri putra Harmoni, Presint 9

Putrajaya

62250

Wilayah Persekutuan Putrajaya

Nama seperti di dalam IC / Name as stated in NRIC

No. kad pengenalan (Baru) / NRIC (New)

Emel / Email

No. telefon bimbit / Mobile phone

Warganegara / Nationality

Tarikh lahir / D.O.B.

Umur / Age

Apakah pendapatan purata kasar bulanan anda? (RM/Bulan) / What is your monthly gross personal income? (RM/Month)

Adakah anda pernah diisytiharkan muflis? / Have you been declared bankrupt?

Pengenalan ID lain / Other ID type

Gelaran / Title

Jantina / Gender

Bangsa / Race

Taraf perkahwinan / Marital status

Adakah anda mempunyai anak? / Do you have children?

Alamat Rumah / Home AddressAlamat baris 1 / Address line 1

Alamat baris 2 / Address line 2

Pekan atau bandar / Town or city

Poskod / Postcode

Negeri / State

Telefon rumah / Home phone

Pemilikan kediaman di atas / Ownership of above property

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Sewa / Rental

0

Sabah

Bekerja - Kerajaan / Employed - Government

Am/Perkeranian / General/Clerical

Kerajaan (Perkhidmatan Awam) / Government (Civil Services)

Tidak berkenaan / None

1.3 Butiran Pekerjaan / Employment Details

Untuk soalan-soalan di bawah, sila isi "Tiada" untuk mana-mana yang tidak berkenaan / For questions below, please fill in "None"whichever not applicable.

GURU BESAR SK CYBERJAYA

Persiaran Bestari, Zon Flagship 2

Cyberjaya

63000

Selangor

Malaysia

TIADA

Bilangan hartanah yang dimiliki anda dan/atau pasangan anda / No. of properties that are currently owned by you and/or your spouse(s)

Negeri kelahiran / State of birth

Status pekerjaan / Employment status

Pekerjaan/Fungsi pekerjaan / Occupation/Job function

Industri / Industry

Kurang upaya / Disability

Nama organisasi atau syarikat / Organization or company name

Alamat pejabat / Office addressAlamat baris 1 / Address line 1

Alamat baris 2 / Address line 2

Pekan atau bandar / Town or city

Poskod / Postcode

Negeri / State

Negara / Country

No. cukai pendapatan LHDN / LHDN income tax file no.

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Medan yang bertanda asterisk merah ( *) merupakan ruangan yang wajib diisi / It is mandatory to fill in the fields with red asterisk ( *).

2. Maklumat Pasangan / Spouse Information

1,212.00

Sila rujuk kepada Kriteria Kelayakan untuk definisi pendapatan purata kasar bulanan. / Please refer to Eligibility Criteria ondefinition of average monthly gross income.

2,976.84

MUHAMAD ZAIN BIN MOKHTAR

No. Kad Pengenalan (Baru) / NRIC (New)

730104146069

Tiada / None

04-Jan-1973

39

Lelaki / Male

60193015750

Melayu / Malay

Bekerja - Swasta / Employed - Private

Guru / Teacher

Lain-lain / Others

Tidak berkenaan / None

Untuk soalan-soalan di bawah, sila isi "Tiada" untuk mana-mana yang tidak berkenaan / For questions below, please fill in "None"whichever not applicable.

JAB.AGAMA ISLAM KUALA LUMPUR

TIADA

TIADA

17035445

Apakah pendapatan purata kasar bulanan pasangan anda? (RM/Bulan) / What is your spouse's average monthly gross personal income?(RM/Month)

Jumlah Pendapatan Keluarga (RM/Bulan) / Total Household Income (RM/Month) :

Nama / Name

Pengenalan ID / ID Type

No. Kad Pengenalan (Baru) / NRIC (New)

Pengenalan ID lain / Other ID type

Tarikh lahir / D.O.B

Umur / Age

Jantina / Gender

No. telefon bimbit / Mobile no.

Bangsa / Race

Status pekerjaan / Employment status

Pekerjaan/Fungsi pekerjaan / Occupation/Job function

Industri / Industry

Kurang upaya / Disability

Butiran Pekerjaan / Employment Details

Nama organisasi atau syarikat / Organization or company name

Nombor pendaftaran organisasi atau perniagaan / Organization or business registration no.

No. cukai pendapatan LHDN / LHDN income tax no.

No. KWSP / KWSP no.

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3. Anak-anak / Children(s)

No. Nama / NameNo kad pengenalan (Baru)/No. passport / NRIC (New)/ Passport no.

Umur / Age Employment status /Status perkerjaan

1 MUHAMAD SHARIZ ZHARFAN BIN MUHAMAD ZAIN 101005100143 2 Tahun /Year(s)

Tidak Bekerja /Unemployed

1

0

Sila isikan butiran anak-anak anda / Please specify children information

Bilangan anak / No. of children

Bilangan anak yang sedang bekerja / No. of children who are currently working?

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4. Maklumat Hartanah / Property Information

4.1 Tempat Tinggal Semasa / Current Accommodation

Flat kos rendah / Low cost flats

Bawah 1000 kaki persegi / Below 1000 sqft

RM501 - RM750

Jenis hartanah rumah semasa / Type of property you are currently staying in

Saiz rumah semasa / What is the size of the current house you are staying in?

Apakah kadar sewa bulanan? (RM/Bulan) / What is the monthly rental? (RM/Month)

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Negeri / State

Wilayah Persekutuan Putrajaya

Selangor

Selangor

Selangor

Sabah

5. Rumah PR1MA / PR1MA Home

3

5.1 Lokasi / Location

Daerah lain, negeri yang sama / Different district, same state

Kawasan atau Zon / Area or Zone(Berdasarkan Pihak BerkuasaTempatan (PBT) / Based on LocalAuthority: Majlis Bandaraya / MajlisPerbandaran / Majlis Daerah)

Putrajaya

Sepang

Kajang

Kuala Langat

Kunak

5.2 Spesifikasi / Specification

Untuk memiliki rumah sendiri / To have my own house

Rumah teres setingkat / Single Terrace linked

3 bilik + 2 bilik air / 3 rooms + 2 bath rooms

1000-1499 kaki persegi / 1000-1499 sqft

5.3 Kawasan Perbandaran atau Kejiranan / Neighbourhood or Township

Balai polis / Police station

Pusat Perubatan / Medical centre

Kedai Rakyat 1Malaysia / Kedai Rakyat 1Malaysia

Pasar pagi/pasar malam/pasar basah / Wet market/morning market/night market

Pusat jagaan Harian Kanak-kanak 1Malaysia / Childcare 1Malaysia

Berdekatan dengan kemudahan seperti kedai, hospital / Close to amenities such as shops, hospital

Berdekatan dengan tempat kerja / Near working place

Berapa ramaikah yang akan menetap di rumah PR1MA ? / How many people in total will be staying in PR1MA home?

Apakah jarak daripada bandar/pusat bandar yang anda boleh pertimbangkan untuk berpindah? / How far away from city/town centre wouldyou consider moving to?

Di manakah lokasi pilihan anda? / Where would you consider moving to?

Pilihan Pertama wajib diisi, pilihan yang seterusnya tidak wajib diisi / It is mandatory to fill up the 1st Choice, the rest is optional

Pilihan pertama / 1st choice

Pilihan kedua / 2nd choice

Pilihan ketiga / 3rd choice

Pilihan keempat / 4th choice

Pilihan kelima / 5th choice

Apakah sebab utama anda ingin membeli rumah baru? / What are the main reasons for buying a new accommodation/house?

Jenis hartanah yang menjadi pilihan / Type of property you will consider to buy

Bilangan bilik tidur/bilik air yang menjadi pilihan / What is your preferred rooms/bathrooms configuration?

Keluasan (kps) / Dimension (sqf)

Nyatakan 5 kemudahan yang perlu ada dalam kawasan kejiranan anda? /What are the top 5 most important amenities should be available in the township/place you will be staying?

Kemudahan Pertama / 1st Amenity

Kemudahan Kedua / 2nd Amenity

Kemudahan Ketiga / 3rd Amenity

Kemudahan Keempat / 4th Amenity

Kemudahan Kelima / 5th Amenity

Apakah 3 kriteria utama semasa memilih rumah baru?What are the top 3 main factors/criteria when selecting a new accommodation/house?

Kriteria Pertama / 1st factor

Kriteria Kedua / 2nd factor

Kriteria Ketiga / 3rd factor

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Kurang sesak, kurang kesesakan trafik / Less congested less traffic jam

5.4 Keperluan Special / Special Needs

TIADA

Sila nyatakan sekiranya anda mempunyai masalah kesihatan yang boleh mempengaruhi jenis pilihan hartanah anda / If you have any medicalproblems that might affect the type of property you need to live in please give details

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6. Lampiran / Attachment(s)

Nama Fail /File Name

Jenis Dokumen /Document Type

Saiz Dokumen (kb)/Document Size (kb)

penyata bank 3bln.pdf Penyata bank / Bankstatement 785.16

kwsp.pdf Penyata EPF / EPF Statement 677.25

surat pengesahan majikan.pdfSurat Pengesahan dariMajikan / EmployerVerification Letter

784.64

DEC_2012_(C01).pdf Slip gaji / Salary slip 126.19EC_DEC_2011.pdf Borang EA/B / EA/B Form 94.16

2,467.39

Sila muat naik dokumen sokongan dan sila rujuk Kriteria Kelayakan untuk senarai dokumen yang diperlukan/Please upload supporting document(s) and refer to Eligibility Criteria for the list of documents required

Jumlah Saiz Fail (kb) / Total File Size (kb)

Page 9: PR1MA_634918547671816805

7. Lain-lain / Others

7.1 Maklumat Lain / Others Information

Pendidikan Menengah Rendah / Lower Secondary

Apabila anda telah selesai mengisi borang permohonan anda, sila klik pada butang "Hantar" untuk menghantar permohonan andasecara elektronik.

NOTA PENTING:Sila tekan butang Hantar HANYA setelah selesai mengisi borang permohonan untuk memastikan permohonan anda adalah muktamad

Once you have completed your application, please click on “submit” to submit your application electronically.

IMPORTANT NOTE:Please click on submit ONLY when you are sure that you have COMPLETELY finalised your application.

Taraf pendidikan / Education level