PERATURAN-PERATURAN OPTIK (PINDAAN) 2014

Alamat kediaman: ……………………………………….…………………………………….....................................

…………………………………………………………………..………………………………………....................................

Alamat perhubungan pos (jika berlainan): ……………………….………………….....................................

…………………………………………………………………..………………………………………….................................

Perihal kelulusan (sepenuhnya): ……………………..…………………………………………………...............

……………………………………………………………………………………………........................................................

Institusi yang memberikan kelulusan: ……………………………………………………………………..........

………………………………………………………………………………………………….................................................

Tarikh kelulusan: ………………………...…………………………………………………………………...................

salinan yang diperakui benar Sijil Kerakyatan (sekiranya berkenaan);

salinan yang diperakui benar diploma, perakuan dsb,yang asal;

………………………………………………………………………………………………………………………………….....

Tarikh: .......................................

....................................................

Tandatangan pemohon

Gambar

P.U. (A) 64 4

Saya, (nama penuh) ………………………………………………………………………………… pemohon yang tersebut di atas, dengan ini mengaku bahawa butir-butir yang dinyatakan dalam permohonan ini adalah benar dan betul dan dokumen yang dilampirkan ialah salinan dokumen asal yang diperakui benar yang berkaitan dengan saya. Saya tidak pernah pada bila-bila masa didapati melakukan kesalahan yang melibatkan fraud, kecurangan atau keburukan akhlak, atau kesalahan yang boleh dikenakan hukuman penjara (sama ada hukuman penjara itu sahaja atau sebagai tambahan atau sebagai ganti suatu denda) selama tempoh satu tahun atau ke atas.

Tarikh: ……………………………….

……………………………………………

Tandatangan pemohon

Saya, (nama penuh) …………………………………………………………………………………………………..........................................

yang beralamat di (alamat penuh) ………………………………………………………………………………......................................

…………………………………………………………………………………………………………………………...................................................

sebagai (kedudukan profesional) …………………………………………………………………………………....................................

dengan ini memperakui bahawa (nama pemohon) ………………………………………………………………...........................

yang permohonannya untuk didaftarkan sebagai …………………………………………………………………..........................

dikemukakan di atas adalah seorang yang saya kenal sendiri dan beliaulah orang yang namanya terdapat pada permohonan ini.

Tarikh: ………………….…………… ………………………………..

Tandatangan

Juruoptik Berdaftar Sepenuhnya/

Optometris Berdaftar Sepenuhnya atau

Peguam bela dan Peguam cara atau seorang Pegawai dalam Kumpulan

Pengurusan dan Profesional

Perkhidmatan Awam

P.U. (A) 64 5

Borang 6

(Peraturan 20)

(Subseksyen 18(2))

PERMOHONAN UNTUK PENDAFTARAN JURUOPTIK

Alamat kediaman: ……………………………………….………………………………..............................................

…………………………………………………………………..…………………………………..........................................

Alamat perhubungan pos (jika berlainan): ……………………….………………….....................................

…………………………………………………………………..…………………………………...........................................

Butir-butir kelulusan:

Perihal kelulusan (sepenuhnya): ……………………..…………………………..............................

Pengalaman Amali:

No. Pendaftaran

Perniagaan

Tahun Pengalaman

Amali

Majikan/Tuan punya

Alamat Pengamalan

salinan yang diperakui benar Sijil Kerakyatan (sekiranya berkenaan);

salinan yang diperakui benar Sijil Pendaftaran Perniagaan (sekiranya ada);

salinan yang diperakui benar Perakuan daripada Majikan;

salinan yang diperakui benar diploma, perakuan dsb, yang asal;

………………………………………………………………………………………………………………………………….....

Tarikh: …………………

................……..………………………...

Tandatangan pemohon

Gambar

P.U. (A) 64 6

Saya, (nama penuh) ………………………………………………………………………………… pemohon yang tersebut di atas, dengan ini mengaku bahawa butir-butir yang dinyatakan dalam permohonan ini adalah benar dan betul dan dokumen yang dilampirkan ialah salinan dokumen asal yang diperakui benar yang berkaitan dengan saya. Saya tidak pernah pada bila-bila masa didapati melakukan kesalahan yang melibatkan fraud, kecurangan atau keburukan akhlak, atau kesalahan yang boleh dikenakan hukuman penjara (sama ada hukuman penjara itu sahaja atau sebagai tambahan atau sebagai ganti suatu denda) selama tempoh satu tahun atau ke atas.

Tarikh: …………………………

…………………………………......

Tandatangan pemohon

Saya, (nama penuh) ……………………………………………………………………………………...........................................................

yang beralamat di (alamat penuh) …………………………………………………………………….....................................................

………………………………………………………………………………………………………………..................................................................

sebagai (kedudukan profesional) …………………………………………………………………….......................................................

dengan ini memperakui bahawa (nama pemohon) ……………………………………………….................................................

yang permohonannya untuk didaftarkan sebagai ………………………………………………....................................................

dikemukakan di atas adalah seorang yang saya kenal sendiri dan beliaulah orang yang namanya terdapat pada permohonan ini.

Tarikh: …………………...

............………………………

Tandatangan

Juruoptik Berdaftar Sepenuhnya/

Optometris Berdaftar Sepenuhnya atau

Peguam bela dan Peguam cara atau seorang Pegawai dalam Kumpulan

Pengurusan dan Profesional

Perkhidmatan Awam

P.U. (A) 64 7

Borang 7

(Peraturan 20)

(Seksyen 19)

PERMOHONAN UNTUK PENDAFTARAN OPTOMETRIS

Alamat kediaman: ……………………………………….……………………………….............................................

…………………………………………………………………..……………………………...................................................

Alamat perhubungan pos (jika berlainan): ……………………….………………….....................................

…………………………………………………………………..…………………………......................................................

Perihal kelulusan (sepenuhnya): ……………………..…………………………………....................................

.........................................................................................................................................................................................

Institusi yang memberikan kelulusan: …………………………………………………...................................

.........................................................................................................................................................................................

Tarikh kelulusan: ………………………...…………………………………..............................................................

.........................................................................................................................................................................................

salinan yang diperakui benar Sijil Kerakyatan (sekiranya berkenaan);

salinan yang diperakui benar diploma, perakuan dsb, yang asal;

………………………………………………………………………………………………………………………………….....

Tarikh: ............................. ..............................................

Tandatangan pemohon

Gambar

P.U. (A) 64 8

Saya, (nama penuh) ………………………………………………………………………………… pemohon yang tersebut di atas, dengan ini mengaku bahawa butir-butir yang dinyatakan dalam permohonan ini adalah benar dan betul dan dokumen yang dilampirkan ialah salinan dokumen asal yang berkaitan dengan saya. Saya tidak pernah pada bila-bila masa didapati melakukan kesalahan yang melibatkan fraud, kecurangan atau keburukan akhlak, atau kesalahan yang boleh dikenakan hukuman penjara (sama ada hukuman penjara itu sahaja atau sebagai tambahan atau sebagai ganti suatu denda) selama tempoh satu tahun atau ke atas.

Tarikh: ……………………………

……………………………………....

Tandatangan pemohon

Saya, (nama penuh) ……………………………………………………………………………………............................................................

yang beralamat di (alamat penuh) …………………………………………………………………........................................................

……………………………………………………………………………………………………….............................................................................

sebagai (kedudukan profesional) ……………………………………………………………..................................................................

dengan ini memperakui bahawa (nama pemohon) ……………………………………………....................................................

yang permohonannya untuk didaftarkan sebagai ………………………………………………....................................................

dikemukakan di atas adalah seorang yang saya kenal sendiri dan beliaulah orang yang namanya terdapat pada permohonan ini.

Tarikh: …………………...

............………………………...

Tandatangan

Juruoptik Berdaftar Sepenuhnya/

Optometris Berdaftar Sepenuhnya atau

Peguam bela dan Peguam cara atau seorang Pegawai dalam Kumpulan

Pengurusan dan Profesional

Perkhidmatan Awam

P.U. (A) 64 9

Borang 8

(Peraturan 20)

(Subseksyen 20(4))

PERAKUAN PENDAFTARAN PENUH JURUOPTIK

No. Perakuan Pendaftaran Penuh:

yang beralamat di pada hari ini telah didaftarkan sepenuhnya sebagai seorang juruoptik berdaftar di bawah subseksyen 18(1) atau (2) Akta Optik 1991 tertakluk kepada sekatan-sekatan dan syarat-syarat yang dikenakan oleh Menteri seperti yang berikut:

Tarikh:

......................................................

Pengerusi

Fi sebanyak RM100.00 telah dibayar. Lihat no. resit bertarikh

P.U. (A) 64 10

Borang 9

(Peraturan 20)

(Subseksyen 20(4))

PERAKUAN PENDAFTARAN PENUH OPTOMETRIS

No. Perakuan Pendaftaran Penuh:

yang beralamat di mempunyai kelulusan telah pada hari ini didaftarkan sepenuhnya sebagai seorang optometris berdaftar di bawah seksyen 19

Akta Optik 1991 tertakluk kepada sekatan-sekatan dan syarat-syarat yang dikenakan oleh Menteri seperti yang berikut:

Tarikh:

......................................................

Pengerusi

Fi sebanyak RM100.00 telah dibayar. Lihat no. resit bertarikh

P.U. (A) 64 11

Borang 10

(Peraturan 21)

(Subseksyen 18(3))

PERMOHONAN UNTUK PENDAFTARAN SEMENTARA

Alamat kediaman: ……………………………………………………………….........................................................

……………………………………………………….............................................................................................................................

Alamat perhubungan pos (jika berlainan): ………………………………….................................................

………………………………………………………………………………………………......................................................................

salinan yang diperakui benar Sijil Kerakyatan (sekiranya berkenaan);

salinan yang diperakui benar Perakuan daripada Kolej;

salinan yang diperakui benar Perakuan daripada Penyelia;

…………………………………………….……………………………………………………………………………………....

Tarikh: ……………………

………………………………

Tandatangan pemohon

Gambar

P.U. (A) 64 12

Saya, (nama penuh) ………………………………………………………………… pemohon yang tersebut di atas, dengan ini mengaku bahawa butir-butir yang dinyatakan dalam permohonan ini adalah benar dan betul dan dokumen yang dilampirkan ialah salinan dokumen asal yang diperakui benar yang berkaitan dengan saya. Saya tidak pernah pada bila-bila masa didapati melakukan kesalahan yang melibatkan fraud, kecurangan atau keburukan akhlak, atau kesalahan yang boleh dikenakan hukuman penjara (sama ada hukuman penjara itu sahaja atau sebagai tambahan atau sebagai ganti suatu denda) selama tempoh satu tahun atau ke atas.

Tarikh : …………………………

……………………………………

Tandatangan pemohon

Saya, (nama penuh) …………………………………………………………………………...........................................................................

yang beralamat di (alamat penuh) …………………………………………………………...................................................................

……………………………………………………………………………………………………….............................................................................

sebagai (kedudukan profesional)……………………………………………………………...................................................................

dengan ini memperakui bahawa (nama pemohon)……………………………………................................................................

yang permohonannya untuk didaftarkan sebagai………………………………………................................................................

yang dikemukakan di atas adalah seorang yang saya kenal sendiri dan beliaulah orang yang namanya terdapat pada permohonan ini.

Tarikh: …………………...

............………………………

Tandatangan

Juruoptik Berdaftar Sepenuhnya/

Optometris Berdaftar Sepenuhnya atau

Peguam bela dan Peguam cara atau seorang Pegawai dalam Kumpulan

Pengurusan dan Profesional

Perkhidmatan Awam

P.U. (A) 64 13

Borang 11

(Peraturan 21)

(Subseksyen 18(3))

PERAKUAN PENDAFTARAN SEMENTARA

No. Perakuan Pendaftaran Sementara:

yang beralamat di yang menghadiri kursus dalam telah pada hari ini didaftarkan sementara di bawah subseksyen 18(3) Akta Optik 1991 tertakluk kepada sekatan-sekatan dan syarat-syarat yang dikenakan oleh Menteri seperti yang berikut:

Tarikh:

…….…..………..………

Pengerusi

Fi sebanyak RM100.00 telah dibayar. Lihat no. resit bertarikh

P.U. (A) 64 14

Borang 12

(Peraturan 22)

(Subseksyen 32(1))

PERMOHONAN UNTUK PERAKUAN PENGAMALAN TAHUNAN BAGI JURUOPTIK

*Nama premis utama amalan: ..........................................................................................................................

*Alamat premis utama amalan: .......................................................................................................................

......................................................................................................................................................................................

Nama premis amalan yang lain (jika ada): .................................................................................................

Alamat premis amalan yang lain: ...................................................................................................................

........................................................................................................................................................................................

No.: ........................................................ (b) Jumlah: ..........................................

Pejabat Pos/Bank dan tarikh: ........................................................................................

*Tarikh: ...............................

.............................................................

*Tandatangan pemohon

CATATAN:-

*Nama premis utama amalan: ..........................................................................................................................

*Alamat premis utama amalan: .......................................................................................................................

........................................................................................................................................................................................

Nama premis amalan yang lain (jika ada): .................................................................................................

Alamat premis amalan yang lain: ...................................................................................................................

........................................................................................................................................................................................

No.: ........................................................ (b) Jumlah: ..........................................

Pejabat Pos/Bank dan tarikh: ........................................................................................

*Tarikh: ...............................

.............................................................

*Tandatangan pemohon

CATATAN:-

iaitu tempat amalan utama, dan di:

iaitu tempat/tempat-tempat amalan yang lain.

Tarikh: ………………………

.......................................

Pendaftar

Fi sebanyak RM50.00 telah dibayar. Lihat no. resit bertarikh

P.U. (A) 64 17

Borang 15

(Peraturan 22)

(Subseksyen 32(2))

PERAKUAN PENGAMALAN TAHUNAN BAGI OPTOMETRIS

No. Pendaftaran Penuh: ……………………………….

MAKA DENGAN INI ADALAH DIPERAKUI bahawa yang beralamat di seorang optometris berdaftar sepenuhnya dengan ini diberi kuasa untuk menjalankan amalan sebagai seorang optometris (tertakluk kepada sekatan-sekatan dan syarat-syarat, jika ada, sebagaimana dinyatakan dalam Perakuan Pendaftaran Penuh) selama tempoh bermula …………...…………… dan berakhir pada ………………………………... di:

iaitu tempat amalan utama, dan di:

iaitu tempat/tempat-tempat amalan yang lain.

Tarikh: ………………………… ...............................................

Pendaftar

Fi sebanyak RM50.00 telah dibayar. Lihat no. resit bertarikh

”.

P.U. (A) 64 18

Dibuat 11 Februari 2014

[KKM-87/A7/1/10; PN(PU2)503/IV]

DATUK SERI DR. S. SUBRAMANIAM

Menteri Kesihatan

P.U. (A) 64 19

OPTICAL (AMENDMENT) REGULATIONS 2014

Residential address: ............................................................................................................................................

.........................................................................................................................................................................................

Address for postal communication (if different): ....................................................................................

........................................................................................................................................................................................

Institution which granted qualification: .....................................................................................................

........................................................................................................................................................................................

Residential address: .............................................................................................................................................

.........................................................................................................................................................................................

Address for postal communication (if different): ....................................................................................

........................................................................................................................................................................................

Particulars of qualification:

Description of qualification (in full): ..........................................................................................

.....................................................................................................................................................................

Practical Experience:

Business Registration

No.

Years of Practical

Experience

Employer/Owner

Address of Practice

Certified true copy of Citizenship Certificate (if applicable);

Certified true copy of Business Registration Certificate (if any);

Certified true copy of Certification by Employer;

Certified true copies of original diplomas, certificates etc.;

..................................................................................................................................................................................

Date: .......................................

............................................

Signature of applicant

Photograph

P.U. (A) 64 23

I, (full name) ................................................................................................................................................................................................

the above-named applicant, hereby declare that the particulars stated in this application are true and correct and the documents attached are certified true copies of original documents which relate to me. I have not at any time been found guilty of an offence involving fraud, dishonesty or moral turpitude, or an offence punishable with imprisonment (whether in itself only or in addition to or in lieu of a fine) for a term of one year or upward.

Date: ....................................... ..........................................

Signature of applicant

I, (full name) ................................................................................................................................................................................................

of having an adress at (full address) ................................................................................................................................................

being (professional status) .................................................................................................. ................................................................

do hereby certify that (name of applicant) ....................................................................................................................................

whose application for registration as a ..................................................................................... .....................................................

submitted above is known to me personally and is in fact the person whose name appears on this application.

Date: .................................

..............................................

Signature

Fully Registered Optician/

Fully Registered Optometrist or

Advocate and Solicitor or an Officer in the Managerial and

Professional Group of the Public Service

P.U. (A) 64 24

FORM 7

(Regulation 20)

(Section 19)

APPLICATION FOR REGISTRATION OF OPTOMETRIST

Residential address: ............................................................................................................................................

.........................................................................................................................................................................................

Address for postal communication (if different): ....................................................................................

........................................................................................................................................................................................

Description of qualification (in full): .......................................................................................................

...................................................................................................................................................................................

Institution which granted qualification: ................................................................................................

...................................................................................................................................................................................

Date of qualification: ......................................................................................................................................

Certified true copy of Citizenship Certificate (if applicable);

Certified true copies of original diplomas, certificates etc.;

..................................................................................................................................................................................

Date: .......................................

............................................

Signature of applicant

Photograph

P.U. (A) 64 25

I, (full name) ....................................................................................................................... the above-named applicant, hereby declare that the particulars stated in this application are true and correct and the documents attached are certified true copies of original documents which relate to me. I have not at any time been found guilty of an offence involving fraud, dishonesty or moral turpitude, or an offence punishable with imprisonment (whether in itself only or in addition to or in lieu of a fine) for a term of one year or upward.

Date: .......................................

..........................................

Signature of applicant

I, (full name) ................................................................................................................................................................................................

of having an adress at (full address) ................................................................................................................................................

being (profesional status) ...................................................................................................................................................................

do hereby certify that (name of applicant) ....................................................................................................................................

whose application for registration as a ...................................................................................... submitted above is known to me personally and is in fact the person whose name appears on this application.

Date: .................................

..............................................

Signature

Fully Registered Optician/

Fully Registered Optometrist or

Advocate and Solicitor or an Officer in the Managerial and

Professional Group of the Public Service

P.U. (A) 64 26

Form 8

(Regulation 20)

(Subsection 20(4))

FULL REGISTRATION CERTIFICATE FOR OPTICIAN

Full Registration Certificate No.:

having an address at on this day has been fully registered as a registered optician under subsection 18(1) or (2) of the Optical

Act 1991 subject to the restrictions and conditions stipulated by the Minister as follows:

Date:

......................................................

Chairman

Fee of RM100.00 paid. See receipt no. dated

P.U. (A) 64 27

Form 9

(Regulation 20)

(Subsection 20(4))

FULL REGISTRATION CERTIFICATE FOR OPTOMETRIST

Full Registration Certificate No.:

having an address at holding the qualification of on this day has been fully registered as a registered optometrist under section 19 of the Optical Act 1991

subject to the restrictions and conditions stipulated by the Minister as follows:

Date:

......................................................

Chairman

Fee of RM100.00 paid. See receipt no. dated

P.U. (A) 64 28

FORM 10

(Regulation 21)

(Subsection 18(3))

APPLICATION FOR PROVISIONAL REGISTRATION

Residential address: ............................................................................................................................................

.........................................................................................................................................................................................

Address for postal communication (if different): ....................................................................................

........................................................................................................................................................................................

Certified true copy of Certification from Supervisor;

Date: .......................................

..........................................

Signature of applicant

Photograph

P.U. (A) 64 29

I, (full name) ................................................................................................................................................................................................

the above-named applicant, hereby declare that the particulars stated in this application are true and correct and the documents attached are certified true copies of original documents which relate to me. I have not at any time been found guilty of an offence involving fraud, dishonesty or moral turpitude, or an offence punishable with imprisonment (whether in itself only or in addition to or in lieu of a fine) for a term of one year or upward.

Date: .......................................

..........................................

Signature of applicant

I, (full name) ................................................................................................................................................................................................

of having an adress at (full address) ................................................................................................................................................

being (professional status) ..................................................................................................................................................................

do hereby certify that (name of applicant) ...................................................................................................................................

whose application for registration as a ..........................................................................................................................................

submitted above is known to me personally and is in fact the person whose name appears on this application.

Date: .................................

..............................................

Signature

Fully Registered Optician/

Optometrist or

Advocate and Solicitor or an Officer in the Managerial and

Professional Group of the Public Service

P.U. (A) 64 30

Form 11

(Regulation 21)

(Subsection 18(3))

PROVISIONAL REGISTRATION CERTIFICATE

Provisional Registration Certificate No.:

having an address at who is attending a course in on this day has been provisionally registered under subsection 18(3) of the Optical Act 1991 subject to the restrictions and conditions stipulated by the Minister as follows:

Date:

......................................................

Chairman

Fee of RM100.00 paid. See receipt no.

dated

P.U. (A) 64 31

Form 12

(Regulation 22)

(Subsection 32(1))

APPLICATION FOR ANNUAL PRACTISING CERTIFICATE FOR OPTICIAN

*Name of principal place of practice: ............................................................................................................

*Address of principal place of practice: .......................................................................................................

........................................................................................................................................................................................

Name of other places of practice (if any): ...................................................................................................

Address of other places of practice: ..............................................................................................................

........................................................................................................................................................................................

No.: .......................................................... (b) Sum: ...............................................

Post Office/Bank and date: ............................................................................................

*Date: ...............................

........................................

*Signature of applicant

NOTES:-

*Name of principal place of practice: ............................................................................................................

*Address of principal place of practice: .......................................................................................................

........................................................................................................................................................................................

Name of other places of practice (if any): ...................................................................................................

Address of other places of practice: ..............................................................................................................

........................................................................................................................................................................................

No.: .......................................................... (b)

Sum: .................................................

Post Office/Bank and date: ..............................................................................................

*Date: ...............................

........................................

*Signature of applicant

NOTES:-

being the principal place of practice, and at:

being other place/places of practice.

Date: ………………… ………….……………

Registrar

Fee of RM50.00 paid. See receipt no. dated

P.U. (A) 64 34

Form 15

(Regulation 22)

(Subsection 32(2))

ANNUAL PRACTISING CERTIFICATE FOR OPTOMETRIST