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I (i) Nama Pegawai: (ii) Jawatan (iii) No Kad Pengenalan (v) No. Pasport Antarabangsa (vi) Alamat Jabatan dn No. Telefon: (vii) Alamat Rumah dan No. Telefon: 2. Butir Lawatan (i) Negara dilawati : (ii) Tujuan Lawatan : (ii) Jika Negara Komunis/Taiwan, nyatakan rujukan surat kelulusan Kementerian Keselamatan Dalam Negeri/Kementerian Luar Negeri sekiranya Telah diperolehi: (iv) Tarikh lawatan daripada: (v) Jumlah hari lawatan : (tarikh bertolak dari Malaysia) hingga (tarikh tiba di Malay.
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