THE MALAYSIAN LIFT AND ESCALATOR ASSOCIATION (MALEA)

No. 42 Jalan Penchala

46050 Petaling Jaya Tel : 03-7910 3003
Selangor Darul Ehsan Email : info@malea.org.my

APPLICATION FOR REGISTRATION OF LIFT COMPETENT PERSON GRADE III

GUIDANCE NOTES:

1. This form must be completed and submitted with the application letter to MALEA at the above address.

2. Please submit the following supporting documents:

3. A certified true copy of Identity Card.

4. Picture (passport size)

5. The letters original declaration from the employer that shows:-

i. Offer letter; and
ii. the daily tasks

6. A certified true copy of Certificate safety and health training

7. A certified true copy of Certificate technical training related with the responsbility

8. A certified true copy of academic qualifications.

9. Resume or Curricular Vitae applicant

* Certified true copy can be done by the Commissioner of Oath or Government Officer Grade A
 APPLICATION FORM
LIFT COMPETENT PERSON GRADE 3

PART ONE : APPLICANT INFORMATION

1.1. Applicant Name :

1.2. Mailing Address :

1.3. Phone No. : 1.4. Fax No. :

1.5. Employer No. :
1.6. Address :

1.7. Phone No. : 1.8. Fax No. :

1.9. Registration No. of Factory/ Workplace :

2.0. Registration No. of Application :

2.1. File No. of Application :

PART TWO : CERTIFICATION OF APPLICANT

I certify that the information contained in this application is the truth. MALEA may reject my
application if the information is incomplete and false.

Applicant Signature : ___________________________ Employer's Stamp

Full Name : ___________________________

Position : ___________________________

Date : ___________________________
 APPLICATION TO BE REGISTERED AS A
LIFT COMPETENT PERSON 3

A. PARTICULARS OF THE CANDIDATE

(To be filled by the Applicant)
1. PERSONAL PARTICULARS

1.1. Name of Candidate (in block letters) 1.2. Date of Birth

______________________________________ ________________________

1.3. Sex 1.4. Identity Card No. *

Male Female ________________________

1.5. Place of Birth 1.6. Citizenship

______________________________________ ________________________

1.7. Approved Lift Firm Name & Registration No. 1.8. Job Designation:
______________________________________ ________________________

1.9. Office Address 1.10. Tel. No.: (Office)

______________________________________ ________________________
______________________________________
______________________________________ 1.11. Tel. No.: (Home)
______________________________________ ________________________

1.12. E- mail address

________________________

2. QUALIFICATION
2.1. Professional Education* Year Qualification
Name of Institution/ University (From- To) Obtained

____________________________ _________ _______________

2.2. Technical Training

____________________________ _________ _______________

_______________ ________________________
Date Signature of Applicant

Note(*) : Please enclosed certified copies of relevant document and latest medical examination report.
B. EXPERIENCE OF THE CANDIDATE (To be filled by the existing CP Lift Grade 1, if any)

1 TRAINING YES/NO DURATION

a) Maintenance __________________

b) Other (Please specify) __________________

2 FIELD EXPERIENCE YES/NO NO. OF MONTHS

(ACCUMULATE)

a) Maintenance/Monthly Inspection __________________

b) Annual/ Regular Inspection __________________

c) 2nd Schedule Inspection __________________

d) Total number of years of experience in __________________

lift industry

C. DECLARATION BY THE CP LIFT GRADE 1

I hereby: -
i. Certify that the above particulars are true and correct to the best of my knowledge; and
ii. Declare that all of the conditions as set out in Paragraph 2 have been fullfilled.

Date : _________________ ____________________________________

Signature

Name of CP Lift Grade I: _______________

CP Lift Grade 1 No. : _______________
APPLICATION AS LIFT COMPETENT PERSON

A. TYPE OF APPLICATION : NEW RENEW GRADE: 3

B. PARTICULARS OF APPLICANT

1 I.C No. / Passport : _______________________________________________________________

Police/ Army

2 Name : _______________________________________________________________

3 Address : _______________________________________________________________

_______________________________________________________________

4 Postcode : ___________________________ 5. City : __________________________

6 State : ___________________________ 7. Date of Birth : _____________________

8 Sex : Male Female

C. ACADEMIC NO. INSTITUTE FIELD STATUS YEAR

QUALIFICATION/
TRAINING

Space for competency renewal application

Competency Expiry Date : _______________________________________________________________

D. DECLARATION
I, certify that all informations given are true.

Date : _________________ ___________________________

Applicant Signature
Name : __________________________
I.C. No. : __________________________

E. INFORMATION ON MEDICAL OFFICER USED TO DO TREATMENT: -

(State the name and address of Medical Officer who used to treat you)

Name of Medical Officer : ___________________________________

Address : ___________________________________
___________________________________

● ORIGINAL COPY SHOULD BE FORWARDED TO MALEA.

● DUPLICATE SHALL BE KEPT BY THE MEDICAL OFFICER WHO DID THE MEDICAL CHECK-UP
F. MEDICAL EXAMINATION (To be filled by Medical Practitioner)

PART 1

Applicant Registration No. at Clinic : ______________________ Registration Date : __________________

General Conditions : ______________________________________________________________________________________

Weight : ___________ kg Height : __________ cm

Urine examination for albumin and sugar (if positive examine further)

Blood pressure : Sistolic : __________________________ Diastolic : __________________________

Eyesight accuracy according to Snellen Chart (in meter)

Without spectacles min 6/60 Right : _____________ Left : _________________

With spectacles min. 6/12 Right : _____________ Left : _________________

* For those who are wearing spectacles. Must be stated in the licence.

ANSWER

Please mark "X" in appropriate column either "Yes" or "No"

No. Description Yes No Remarks

1 There is defect in eyesight (Istihara Chart)?
2 There is defect in field eyesight (Field Vision)?
3 There is evidence of defect in nerve system?
4 There are proofs in psychiatric disease (Psychiatric)?
5 Has the applicant show any symptons of alcoholic and drug abuse?
6 Have imperfection from or physical disability?
7 Have evidence of abnormality in cardiovascular system?
8 Whether applicant has uncontrolled high blood pressure?
9 Has the applicant suffer diabetes which is not property controlled?
10 Have hearing disability?
11 Have evidence of abnormality in respiration system?
12 Further examination carried out and the results are :-
a) ___________________________________________________________
b) ___________________________________________________________
c) ___________________________________________________________

13 Other views or observations by Medical Pratitioner :-

___________________________________________________________
___________________________________________________________
 PART II

Please answer the following questions on your healt history. Please indicate "x" in appropriate box either
Yes or No. If "Yes", please explain under remarks column.

Do you have historical background or are being experienced the following disease: -

No. Description Yes No Remaks

1 Eye Problem
● Cataract
● "Monocular" view
● Other which cause view obstacle
2 Unable to identify prime colours
[red, green, yellow (amper)]
3 Difficult to see in the dark
4 Any type of fits and cramp
5 Serious head injury
6 Dizzy attack or dizzyness
7 Serious headache or migrane
8 Major brain operation
9 Stroke ("residual" defects)
10 Diabetes in insulin treatment
11 Mental illness
12 Liquor abuse in the past 5 years
13 Drug abuse in the past 5 years
14 Spina bifida (Spina Defect)
15 Limb imperfection or defect
● Limited movement of joint
● Serious limb defect
● Serious amputation
16 Heart attack/ high blood pressure/palpitation
17 Asthma/ blood vomiting/ chronic cough
18 Deaf
● Deaf wholly
19 Chronic kidney disease
20 Any repeated treatment
21 Any disease of injury not mentioned above
 PART III

MEDICAL EXAMINATION RESULT

I, certify that myself on this day had examined applicant ________________________________

Identity Card Number __________________________ Answers to the questions above are true
to the best of my knowledge and belief.

From the medical observations and examination, I have found that the applicant physically
and mentally is

Healthy (Medically Fit) Unhealthy (Medically Unfit)

Medical Practitioner Signature : ___________________________________

Name and qualification of medical practitioner: -

__________________________________________________________________________________
__________________________________________________________________________________

Address :
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

MMC Registration No.: ___________________________

Clinic Registration No.: ___________________________

Date : ___________________________

FOR MALEA USE