ApplicationDirect Form - Complete.pdf - Malaysia My Second Home

For direct application only
Please tick ()
MALAYSIA MY SECOND HOME (MM2H) CENTRE APPENDIX 1
Ministry of Tourism Malaysia
1. Letter of Application (cover letter);
o
MALAYSIA MY SECOND HOME (MM2H) PROGRAMME
CHECKLIST FOR DIRECT APPLICATION
Include information on personal background, intention to join the MM2H Programme, if
joining as a single or with family and briefly explain how you will support your stay in
Malaysia (financial capabilities)
For official use
Please tick ()
2. A copy of resume by the main applicant which includes the following information:
o
o
o
Academic qualification
Working experience
Skills or expertise acquired
3. One (1) copy of MM2H Application Form (downloadable from MM2H website)
Note:
Form has to be completed individually for main applicant and all dependents.
4. Three (3) copies of IM.12 Form – Social Visit Pass
o One (1) original copy (form is downloadable from MM2H website); and
o Two (2) Photostat copies.
Note: Form has to be completed individually for main applicant and all dependents.
5. Four (4) coloured passport sized photographs (3.5 x 5.0 cm)
6. Copy of Passport/ Travel documents
o One (1) copy with certification on personal particulars page (all pages)
o Two (2) copies of personal particulars page
Note : Copy of the previous passport is required if main applicant/dependent(s) has
renewed passport within the last 12 months
7. Letter of Good Conduct from your relevant government agency
8. Self declaration on main applicant’s/ dependents health conditions – Form RB I
(downloadable from MM2H website)
9. Certified copy of Marriage Certificate (if accompanied by spouse)
Updated as of May 2013 1

For direct application only
Please tick ()
MALAYSIA MY SECOND HOME (MM2H) CENTRE APPENDIX 1
Ministry of Tourism Malaysia
10. Certified copy of Birth Certificate/ legal documents (if accompanied by children/ adopted
children/ stepchildren/ parents);
o
o
o
Letter of Confirmation from Medical Specialist/ General Practitioner (if accompanied by
children aged 21 years and above with disabilities).
Statutory Declaration by main applicant to bear all expenses and financial requirements
during stay in Malaysia for dependents.
Legal custody documents (for sole custody) and letter of authorization from other parent
(for divorced parents accompanied by children)
For official use
Please tick ()
11. Certified Copy(s) of latest 3 months bank statement/ other related financial document(s) to
indicate the financial capability to support stay in Malaysia;
12. Certified copies of latest 3 months payslip & income statement (if employed/ pension
slip/etc)
13. Financial Authorization Letter; to verify the financial documents with the relevant financial
Institutions (downloadable from MM2H website)
IMPORTANT NOTES:
o All copies must be certified TRUE COPIES OF ORIGINAL DOCUMNTS by EMBASSY/ HIGH COMMISSION/
SOLICITOR/ JUSTICE OF PEACE/ NOTARY PUBLIC/ COMMISSIONER OF OATHS/ GOVERNMENT OFFICIAL.
o Where original documents are not in ENGLISH, translation must be done by a qualified translator and
CERTIFIED.
o Dependent(s) refer to:
o Spouse
o children aged below 21 years (maximum 6 months before reaching 21 years old at time of
application) and not married; and
o parent(s) of main applicant aged 60 years and above.
o Application to include parent(s) as dependents is to be submitted AFTER main applicant’s application has
been approved.
o All documents enclosed with the present application become the property of the Malaysia My Second Home
(MM2H) Centre and will not be returned.
For APPROVED Participants:
o Security bond is to be submitted for main applicant only
o However, for dependents added after application has been approved, Personal Bond has to be
submitted for each dependent.
o The Security Bond Form must be stamped (RM10.00) by the Stamping Office in Inland Revenue Board of
Malaysia
o The Security Bond is payable in the form of Cash or Bank Draft to the KETUA PENGARAH IMIGRESEN
MALAYSIA
o The Security Bond Fee can be withdrawn if the participant/ dependent decides to exit from the MM2H
Programme
o The amount chargeable is according to Country of Origin of the applicant/ participant. Please refer to Rate of
Security Bond by Country.
Updated as of May 2013 2

FOR INDIVIDUAL DIRECT APPLICANT / SPOUSE v1.10
MINISTRY OF TOURISM MALAYSIA
Malaysia My Second Home Centre
Telephone: +603 88917424 Fax: +603 88917414
APPLICATION FORM FOR THE MALAYSIA MY SECOND HOME PROGRAMME
A. GENERAL
Please tick for applied category:
50 Years And Above Below 50 Years
Please tick if applicant is accompanied by
Passport-sized
Photograph of
Applicant (coloured)
(3.5 x 5.0 cm)
3 pieces
Spouse
Children
Please tick location of stay
Peninsular Malaysia Sabah Sarawak
For the age category 50 years and above only, please specify preferred financial requirement (if application is
approved):
Fixed Deposit of RM150,000
Monthly government- approved pension of RM10,000
B. PARTICULARS OF APPLICANT
1. Full Name (Capital Letters)
2. Please tick () Gender Male Female
Ex-Malaysian Malaysian I/C :
3. Marital Status [Please tick ()] Single Married Divorced Widow/ Widower
Other
Please Specify:
4. Place of Birth (Country)
5. Date of Birth (dd/mm/yyyy) / /
6. Nationality
Updated May 2012
Page 1 of 5

FOR INDIVIDUAL DIRECT APPLICANT / SPOUSE v1.10
7. Passport Number
8. Date of Expiry (dd/mm/yyyy) / /
9. Permanent Address
10. Mailing Address
11. E-mail Address (if any)
Country Code Area Code Number
12. Telephone Number 1) - -
2) - -
I) If currently employed (Q13 – Q16):
13. Current Employment
14. Income (Per Annum)
15. Current Employer/
Organisation
16. Employer’s Address
Updated May 2012
Page 2 of 5

FOR INDIVIDUAL DIRECT APPLICANT / SPOUSE v1.10
II) If retired (Q17 – 20):
17. Last employment
18. Pension Received
(Per Annum) (if any)
19. Last Employer/ Organsation
20. Address of Last Employer/
Organisation
21. Working Experience
No. Position Organisation Year
1.
2.
3.
4.
5.
Applicant Signature
Date
Note: This form is to be submitted together with documents / information as per listed in Appendix A.
Compulsory to be completed by applicant.
Updated May 2012
Page 3 of 5

FOR INDIVIDUAL DIRECT APPLICANT / SPOUSE v1.10
C. DECLARATION BY INDIVIDUAL DIRECT APPLICANT
I , Passport No , issued by the
Government of
agree that:
1. All information given in the application form and the attached supporting documents are genuinely
correct and true;
2. that I hereby authorize the Malaysia My Second Home (MM2H) Centre, under the Ministry of Tourism
Malaysia to verify my financial records with the financial institutions as listed in items (12) and (13) of
Appendix A; and
3. that any false information given by me as the main applicant will result in the Social Visit Pass issued
to me and my dependents (if applicable) under this Programme cancelled without further notice.
Dated this (day) of (date) in the month of of the year
at
in the State of ;
Country ;
(address)
Date :
Signature of the above named:
Signed and executed by the above named in my presence :
Signature of Witness :
Fullname of Witness :
Nationality :
Passport/ MyKad Number :
Date :
Updated May 2012
Page 4 of 5

FOR INDIVIDUAL DIRECT APPLICANT / SPOUSE v1.10
* For office use only :
Individual
With wife [Number of wives : person(s)]
With children [Number of children : person(s)]
Additional Information :
* IMPORTANT :
o No fee is chargeable for individual direct application to participate in the Malaysia My Second Home
(MM2H) Programme.
o The MM2H Centre under the Ministry of Tourism Malaysia will not be held responsible for any nonperformance
by unauthorised third parties who assist with your application.
o Submission of application by third parties for the MM2H Programme is only authorised to MM2H Licensed
Agents. A list of registered MM2H licensed agents is available on the “LICENSING” page of the MM2H
Centre website at http://www.mm2h.gov.my.
Updated May 2012
Page 5 of 5

FOR CHILDREN BELOW 21 YEARS v1.1
MINISTRY OF TOURISM MALAYSIA
Malaysia My Second Home Centre
Telephone: +603 88917424 Fax: +603 88917414
APPLICATION FORM FOR THE MALAYSIA MY SECOND HOME PROGRAMME
Passport-sized
Photograph of
Applicant (coloured)
(3.5 x 5.0 cm)
A. PARTICULARS OF APPLICANT
1. Full Name (Capital Letters)
2. Please tick () Gender Male Female
3. Place of Birth (Country)
4. Date of Birth (dd/mm/yyyy) / /
5. Nationality
6. Passport Number
7. Date of Expiry (dd/mm/yyyy) / /
8. Please tick () Student Pass Yes No
9. Student Pass Number (if any)
10. School/ College/ University
(if any)
Page 1 of 2

FOR CHILDREN BELOW 21 YEARS v1.1
11. Field of Study (if any)
12. Mailing Address
Country
Code
Area Code
Number
13. Telephone Number 1) - -
2) - -
Applicant Signature
Date
Note: This form is to be submitted together with the main/ principal application.
Page 2 of 2

JABATAN IMIGRESEN MALAYSIA
BORANG PERMOHONAN PAS LAWATAN
VISIT PASS APPLICATION FORM
PERATURAN-PERATURAN IMIGRESEN, 1963 [Peraturan 11(12) dan 11(15)]
IM. 12 – Pin. 1/97
*Jenis Pas
Type of Pass
Iktisas
Professional
Sosial
Social
Berniaga
Business
Kerja Sementara
Temporary Employment
*Jenis Permohonan
Type of Application
Baru
New
Lanjutan
Extension
A. MAKLUMAT PEMOHON
PARTICULARS OF APPLICANT
1. Nama Penuh (Huruf Besar)
Full Name (Capital Letter)
Gambar Pemohon
Photograph Of
Applicant
(3.5 cm 5.0 cm)
2. *Jantina
Gender
Lelaki
Male
Perempuan
Female
3. Tempat/Negara Lahir
Place/Country of Birth
4. **Tarikh Lahir
Date of Birth
hari bulan tahun
day month year
5. Warganegara
Nationality
B. MAKLUMAT PASPORT PERJALANAN / DOKUMEN PERJALANAN
PARTICULARS OF PASSPORT / TRAVEL DOCUMENT
6. Jenis Dokumen Perjalanan
Type of Travel Document
7. Nombor
Number
8. Tempat / Negara Dikeluarkan
Place / Country of Issue
C. MAKLUMAT PENGANJUR DI MALAYSIA
PARTICULARS OF SPONSOR IN MALAYSIA
10. Nama Penuh (Huruf Besar)
Full Name (Capital Letter)
11. No. Kad Pengenalan
NRIC
9. **Sah Sehingga
Valid Until
12. No. Telefon
Telephone No.
hari bulan tahun
day month year
13. Alamat
Address
Negeri
State
D. KEPERLUAN VISA
VISA REQUIREMENT
14. *Adakah Visa Diperlukan
Visa Requirement
Ya
Yes
Tidak
No
15. *Jenis Visa
Type of Visa
Tarikh
Date
Sekali Perjalanan
Single Entry
• Borang ini hendaklah ditaip. Tandakan (x) dalam petak yang berkenaan.
This form should be typed. Mark (x) in the appropriate box.
Berulangkali Perjalanan
Multiple Entry
Tandatangan Pemohon / Penganjur
Signature of Applicant / Sponsor
** Format Tarikh 99/99/9999
Date Format DD/MM/YYYY

BORANG RB I
RB I Form
MEDICAL REPORT
FOR MALAYSIA MY SECOND HOME PROGRAMME
PERINGATAN
Reminder
BAHAGIAN II DAN II HENDAKLAH DIISI OLEH PEMOHON YANG BERKENAAN
Part I and II are to be completed by the applicant
1. BAHAGIAN I : BUTIR-BUTIR PERIBADI PEMOHON
Part I :
Personal Particulars of Applicant
a) NAMA PENUH :
Fullname :
(DALAM HURUF BESAR / IN CAPITAL LETTERS)
b) NAMA LAIN (JIKA ADA) :
Other Name (if any) (DALAM HURUF BESAR / IN CAPITAL LETTERS)
c) JANTINA :
Sex :
d) NOMBOR PASPORT :
Passport Number :
e) TARIKH DAN TEMPAT LAHIR :
Date and Place of Birth :
2. BAHAGIAN II : LATAR BELAKANG KESIHATAN
Part II :
Medical History
a) ADAKAH ANDA PERNAH MENGHADAPI PENYAKIT BERIKUT?
Have you every suffered from the following ailments?
i. PENYAKIT OTAK
Mental Illness
YA TIDAK JIKA YA, BERI ULASAN
Yes No If yes, give brief details
ii.
iii.
BATUK KERING
Tubercolosis
GILA BABI
Epilepsy
1

BORANG RB I
RB I Form
YA TIDAK JIKA YA, BERI ULASAN
Yes No If yes, give brief details
iv.
LELAH
Chronic Asthma
v. HEPATITIS A / B
vi.
AIDS
vii.
KENCING MANIS
Diabetes Mellitus
viii. PENYAKIT JANTUNG
Heart Disease
b) RANGSANGAN BERFUNGSI TIDAK BERFUNGSI
Senses Functioning Not Functioning
i. RASA
Taste
ii.
iii.
iv.
BAU
Smell
SENTUHAN
Touch
PENGLIHATAN
Vision
v. PENDENGARAN
Hearing
2

BORANG RB I
RB I Form
DECLARATION BY APPLICANT
I , Passport No. ,
issued by the Government of
agree that:
1. All information given in the application form and the supporting documents are genuinely
correct and true; and
2. Any false information given by the applicant / Licensed Company will result in the Social
Visit Pass issued under this Programme being cancelled without further notice.
Date this day of (month) (year) at
in the State of ,
Country .
(address)
Date :
Signature of the abovenamed
3

Director
Malaysia My Second Home Centre
Level 10, No 2, Tower 1,
Jalan P5/6, Precinct 5,
62200 Putrajaya,
MALAYSIA.
Date:
AUTHORIZATION LETTER
I /we __________________________ Passport Number _______________________ hereby
attached the financial statements with Account No _____________________________ from
the _______________________________________ (the said financial institution(s)) for the
purpose of participation in Malaysia My Second Home Programme.
I /we hereby give permission/consent to the authorised officer(s) from Malaysia My Second
Home Centre, Ministry of Tourism to verify my/our financial status or account with the said
financial institution (s).
The permission hereby given is solely for the purpose of my/ours participation in the Malaysia
My Second Home Programme.
Signature,
_______________________
Name:
Address:
Telephone Number:

GOVERNMENT OF MALAYSIA
Immigration Ordinance, 1959
(F.P.M. 12 of 1969)
Immigration of Malaysia Regulation, 1963
(F.L.W. 228/63)
SECURITY BOND
(Regulations 18)
Stamp
RM10.00
By the stamping
office in Inland
Revenue Board
of Malaysia
Where’s it is a condition of the issue of a
to me / the said
of
that there furnished by me / on behalf of the
said security in the sum of as
a guarantee that I / the said will comply with the provisions of the above Ordinance and of
any regulations made there under and with any conditions imposed in respect of, or
instructions endorsed on such
pass.
Now I,
NRIC
of
do hereby bind myself that I / the said
will comply with the provisions of the above Act and of any regulations made
there under and with any special conditions imposed in respect of, or instructions endorsed
on such
pass.
And in case of my / the said
making default therein, I hereby bind myself to forfeit to the Government of Malaysia the sum
of
which I hereby deposited with the Government of Malaysia vide
Receipt No. .
Dated this day of at in
the state of .
Signature of the abovenamed
Signed and executed by the abovenamed
In my presence
Signature of Witness :
Fullname of Witness :
Address of Witness :
FILE REF :
Note : The amount chargeable is according to country of origin of the participant : refer to Rate of
Security Bond by country

Security Bond/ Bank Guarantee Rates
RM 2000.00
Canada
USA
Colombia
Angola
Burkina Faso
Burundi
Cameroon
Central African Republic
Republic Congo
Republic Democratic Congo
Cote D'Ivoire
Djibouti
Equatorial Guinea
Eritrea
Ethiopia
Guinea-Bissau
Ghan
Liberia
Mali Mozambique
Niger
Nigeria
Rwanda
Western Sahara
RM1500.00
Saudi Arabia
Africa
Australia
British C.I
Brunei
China
Europe
Iran
Iraq
Portugal C.I
Taiwan
Tunisia
Vietnam
RM500.00
Indonesia
RM1000.00
Japan
South Korea
Macao
Hong Kong
RM 750.00
Bangladesh
Phillipines
India
Myanmar
Nepal
Pakistan
Sri Lanka
RM300.00
Thailand
RM1000.00
Japan
South Korea
Macao
Hong Kong
Fee for other
countries is
RM1500.00
RM200.00
Singapore
Source : http://www.imi.gov.my/index.php/en/main-services/visa/security-bond
Last Updated on Friday, 09 March 2012 02:10

BORANG RB II
RB II Form
MEDICAL REPORT
FOR MALAYSIA MY SECOND HOME PROGRAMME
PERINGATAN
Reminder
BAHAGIAN II DAN II HENDAKLAH DIISI OLEH PEMOHON YANG BERKENAAN
Part I and II are to be completed by the applicant
1. BAHAGIAN I : BUTIR-BUTIR PERIBADI PEMOHON
Part I :
Personal Particulars of Applicant
a) NAMA PENUH :
Fullname :
(DALAM HURUF BESAR / IN CAPITAL LETTERS)
b) NAMA LAIN (JIKA ADA) :
Other Name (if any) (DALAM HURUF BESAR / IN CAPITAL LETTERS)
c) JANTINA :
Sex :
d) NOMBOR PASPORT :
Passport Number :
e) TARIKH DAN TEMPAT LAHIR :
Date and Place of Birth :
2. BAHAGIAN II : LATAR BELAKANG KESIHATAN
Part II :
Medical History
a) ADAKAH ANDA PERNAH MENGHADAPI PENYAKIT BERIKUT?
Have you every suffered from the following ailments?
i. PENYAKIT OTAK
Mental Illness
YA TIDAK JIKA YA, BERI ULASAN
Yes No If yes, give brief details
ii.
iii.
BATUK KERING
Tubercolosis
GILA BABI
Epilepsy
1

BORANG RB II
RB II Form
YA TIDAK JIKA YA, BERI ULASAN
Yes No If yes, give brief details
iv.
LELAH
Chronic Asthma
v. HEPATITIS A / B
vi.
AIDS
vii.
KENCING MANIS
Diabetes Mellitus
viii. PENYAKIT JANTUNG
Heart Disease
b) RANGSANGAN BERFUNGSI TIDAK BERFUNGSI
Senses Functioning Not Functioning
i. RASA
Taste
ii.
iii.
iv.
BAU
Smell
SENTUHAN
Touch
PENGLIHATAN
Vision
v. PENDENGARAN
Hearing
3. BAHAGIAN III : PENGESAHAN DOKTOR
Part III :
Certification by Doctor
TO BE COMPLETED BY A REGISTERED DOCTOR
I have this day examined
Passport No.
and certify that:
i. He/ She is not suffering from any disease and is healthy.
2

BORANG RB II
RB II Form
ii.
iii.
iv.
He/ She is not very healthy but is not suffering from any
contagious or infectious disease.
He / She is not healthy and is suffering from contagious
or infectious disease which makes his/ her presence
dangerous to the community.
He / She is not healthy and unfit for long distance travel,
and chances of recovery is very slim.
Signature and
Name of Doctor :
Position Held :
Official Seal :
Dated this day of (month) (year).
3