FIWPS111Eb_E2 – IPA Work Permit 0 77958517 / 15 SEP 2020 EMPLOYER'S COPY

AL TYRES COOPERATION
150C PAYA LEBAR ROAD
SINGAPORE 409052

15 Sep 2020

NAME OF FOREIGN WORKER

Your application is approved ZHAO HAIJIANG

WORK PERMIT NO.
0 77958517
Dear Sir / Madam PASSPORT NO.
E15619651
DATE OF APPLICATION
We are pleased to inform you that ZHAO HAIJIANG's Work
15 SEP 2020
Permit application has been approved in-principle. Please bring CPF SUBMISSION NO
your new worker to Singapore before this approval expires on 14 53142475L - PTE - 01
Dec 2020. MONTHLY LEVY RATE
S$250-$650
The next page lists the steps you need to take for your worker to SB TRANSMISSION REF NO

be issued a Work Permit card. Your worker can start work on the 3925749
second day of the arrival in Singapore while waiting for the steps
to be completed.

You must complete the steps within 14 days of the worker's

arrival. If you no longer wish to hire the worker, cancel the in-
principle approval to stop the levy charges and send the worker
home. If you do not take any action, we will eventually withdraw
the approval, and levy will be charged till then.

Yours sincerely

Penny Han (Mrs)

Controller of Work Passes

• You must comply with the conditions stated on this letter and the Employment of Foreign
Manpower Act, including the conditions and regulatory conditions in the Employment of
Foreign Manpower (Work Passes) Regulations 2012. MOM will take action on non-
compliance. You can read the rules at www.mom.gov.sg
• The actual monthly levy varies from month to month, depending on your workforce profile.

Ministry of Manpower Work Pass Division

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FIWPS111Eb_E2 – IPA Work Permit 0 77958517 / 15 SEP 2020 EMPLOYER'S COPY

What you must do to get the Work Permit card:

Before they arrive After they get here

Check their employment details in the Work Within 14 days
Permit application form.
Send them to a Singapore-registered doctor
If there is an error, visit (www.mom.gov.sg/update-wp- for their medical examination.
details) to upload the supporting documents.
Make sure they bring along the medical examination
form (go to www.mom.gov.sg > search for full medical
Send them the Employee's Copy of the In- examination form for foreigner workers) and their In-
Principle Approval letter. Principle Approval letter.
It is their visa and must be shown to Immigration to
enter Singapore. Some jobs require professional registration
(e.g. medicine, law) or licensing (e.g.
Send them a copy of their employment massage establishment licensing from
contract. Police) to be carried out in Singapore. This
approval does not exempt the pass holder or
This contract must state their job scope, working days
and hours, basic monthly salary and terms such as the employer from these requirements.
deductions and leave entitlements.

Log in to our Online Foreign Worker Address

Give MOM a $5,000 Security Bond backed by
Service (OFWAS) to register their Singapore
a bank or an insurance guarantee valid for 26
residential address and mobile number.
months.
Please use ''WP Online (Enquire > Security Bond
Status)'' to confirm that MOM has received the bond,
before arranging your worker to come to Singapore. If Log in to WP Online to get the Work Permit
MOM does not receive the bond by the time your card issued.
worker arrives, your worker will not be allowed into
Singapore and you will have to send the worker
home immediately at your own cost. When your request has been approved,
please print the Notification Letter.
Buy Work Injury Compensation Insurance for Follow the instructions on the Notification Letter to
them. receive the Work Permit card.

An SMS/email alert will be sent to you before

we deliver the card.

Ministry of Manpower Work Pass Division

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FIWPS111Eb_W2 – IPA Work Permit 0 77958517 / 15 SEP 2020 EMPLOYEE'S COPY

ZHAO HAIJIANG
C/O
AL TYRES COOPERATION
150C PAYA LEBAR ROAD
SINGAPORE 409052

15 Sep 2020

NAME OF FOREIGN WORKER

Your application is approved ZHAO HAIJIANG

WORK PERMIT NO.
您的申请已获得批准 0 77958517

Dear ZHAO HAIJIANG Before you leave home

在您离家前
Your application for a Work Permit has been approved in-
Check your employment details on
principle. This letter is proof of this and you can: page 2.
• Use it as a visa to enter Singapore.
检查第 2 页上的雇佣详细信息。
• Start work on the second day of your arrival.

If you do not enter Singapore by 14 Dec 2020, this Within 14 days of your arrival
在抵达后 14 天内
approval will expire.
The steps to receive your Work
您的工作准证申请原则上已获得批准。此信是批准证明，您可
Permit card must be completed.
以：
• 用它作为进入新加坡的签证 完成获得工作准证卡的所需步骤。
• 在抵达新加坡的第二天开始工作
如果您未在 14 Dec 2020 抵达新加坡，本批准信将失效。

Yours sincerely

Penny Han (Mrs)

Controller of Work Passes

Make sure this approval is still valid using www.mom.gov.sg > search for 'validity check' > click 'Work Permit Validity
Check via Work Permit Online (Non-login)'.
通过以下方式核实此批准是否依然有效：访问 www.mom.gov.sg > 搜索 ''validity check'' > 点击 ''Work Permit Validity
Check via Work Permit Online (Non-login)'' 。

Ministry of Manpower Work Pass Division

Web http://www.mom.gov.sg Contact Us http://www.mom.gov.sg/contact Page 1 of 5
FIWPS111Eb_W2 – IPA Work Permit 0 77958517 / 15 SEP 2020 EMPLOYEE'S COPY

*077958517150920* SB Transmission Ref No:3925749

Check your employment details

If you find a problem, please contact your employer or employment agent.
检查您的雇佣详细信息
如发现问题，请联系您的雇主或职业介绍代理人。

YOUR NAME DATE OF BIRTH / SEX NATIONALITY/CITIZENSHIP

姓名 出生日期 / 性别 国籍
ZHAO HAIJIANG 09 APR 1991 / MALE CHINESE
PASSPORT NUMBER WORK PERMIT NUMBER / FIN DATE OF APPLICATION
护照号码 工作准证号码 / FIN 申请日期
E15619651 0 77958517 / G8692655K 15 SEP 2020
NAME OF EMPLOYER INDUSTRY OCCUPATION
雇主名称 行业 职业
AL TYRES COOPERATION MANUFACTURING MOTOR VEHICLE MECHANIC
BASIC MONTHLY SALARY FIXED MONTHLY ALLOWANCES FIXED MONTHLY SALARY
基本月薪 每月固定补贴 固定月薪
S$ 600 S$ 250 S$ 850
MONTHLY HOUSING, AMENITIES AND SERVICES MONTHLY DEDUCTION FOR OTHERS MONTHLY SALARY AFTER TAKING INTO ACCOUNT
DEDUCTIONS 每月其他扣除 FIXED MONTHLY ALLOWANCES AND DEDUCTIONS
每月住宿，设施和服务扣除 S$ 0 每月固定补贴和扣费之后的月薪
S$ 0 S$ 850
HOUSING PROVIDED S'PORE EMPLOYMENT AGENCY (EA) AGENCY FEE TO BE PAID TO S'PORE EA (EXCLUDE
是否提供住宿 新加坡雇佣代理 FEES FOR OVERSEAS EXPENSES)
工友向新加坡雇佣代理支付的中介费用（不
YES INTALENTGENT PTE. LTD.
包括海外支出的费用）
S$ 850

Get a copy of your employment contract. It should state your job scope, working days and hours, basic monthly salary
and terms such as deductions and leave entitlements.
取得雇佣合同的副本。合同应说明您的工作范围、工作日和工作时间、每月的基本工资以及扣款和休假权等条款。
Do not pay any fees for the $5000 security bond, levy, work permit application or renewal or cancellation, medical
insurance or examinations, training courses and the cost of your journey home. These fees are to be paid by your
employer.
不要支付任何 $5000 担保函、纳税、工作准证的申请或续约或取消、医疗保险或体检、培训课程和回乡的费用。这些
费用应由您的雇主承担。

Ministry of Manpower Work Pass Division

Web http://www.mom.gov.sg Contact Us http://www.mom.gov.sg/contact Page 2 of 5
FIWPS111Eb_W2 – IPA Work Permit 0 77958517 / 15 SEP 2020 EMPLOYEE'S COPY

Know your rights and responsibilities

了解自己的权利和责任

You can only work in Singapore as a / an MOTOR VEHICLE MECHANIC for AL TYRES
COOPERATION.
您只能作为 MOTOR VEHICLE MECHANIC 为 AL TYRES COOPERATION 在新加坡工作。

Your employer can reduce your monthly salary only if you agree.
Do not sign on any documents if you do not agree. If your employer reduces your salary without your
agreement, you should approach MOM.
只有经您同意后，您的雇主才可以减少您的月薪。
不要在您不同意的文件上签字。如果您的雇主未经您同意而减少你的薪金，您应向新加坡人力部反应。

You or your employer can end your employment at any time with sufficient notice. When this
happens, you will not be allowed to stay in Singapore to find another job.
If you go missing during employment, your employer can cancel your Work Permit. If you continue to be
in Singapore, you may be fined, jailed or caned for overstaying.
在有充分通知的情况下，您或您的雇主可随时终止您的雇佣。 这时您不能滞留新加坡并寻找其他工作。
如果您在雇佣期间失踪，您的雇主可以取消您的工作准证。如果您继续留在新加坡，您将因滞留不归而被
处以罚款、监禁或鞭刑。

Ministry of Manpower Work Pass Division

Web http://www.mom.gov.sg Contact Us http://www.mom.gov.sg/contact Page 3 of 5
FIWPS111Eb_W2 – IPA Work Permit 0 77958517 / 15 SEP 2020 EMPLOYEE'S COPY

Know your rights and responsibilities

了解自己的权利和责任

You must obey the Employment of Foreign Manpower Act and the Conditions of Work Permit. If
you don't, MOM can revoke your Work Permit, prosecute and send you home.
You may read the rules at www.mom.gov.sg.
您必须遵守新加坡雇佣外籍劳工法 (Employment of Foreign Manpower Act) 和工作准证条款 (Conditions
of Work Permit) ,否则您的工作准证可能被撤销.您也可能遭起诉或遣返或两者兼施.
您可以在 www.mom.gov.sg 查阅规则。

If your employer ends your contract within 6 months, you can get back 50% of the agency fee
that you paid to the Singapore Employment Agency (EA).
The Singapore EA must also issue you receipts for all payments made to them.
如果您的雇主在六个月内终止您的雇佣合约，您将能取回您向新加坡雇佣代理支付的 50% 费用。
新加坡雇佣代理也必须为您所交纳的任何费用提供收据。

If you use an agent in your home country/region, be careful about fees and promises.
The Singapore Government is unable to help you with disputes with
your agent in your home country/region.
如果您在新加坡的工作是通过您本国雇佣代理公司所安排，请留意相关的其费用和所有的承诺。
新加坡政府将无法帮助您处理您与您本国雇佣代理公司之间的纠纷。

Ministry of Manpower Work Pass Division

Web http://www.mom.gov.sg Contact Us http://www.mom.gov.sg/contact Page 4 of 5
FIWPS111Eb_W2 – IPA Work Permit 0 77958517 / 15 SEP 2020 EMPLOYEE'S COPY

Receive your Work Permit card

获得工作准证卡

Once you arrive in Singapore, your employer must complete the following steps within 14 days.
Otherwise, this approval will be withdrawn and you may be sent home.
当您抵达新加坡后，您的雇主必须在 14 天内完成以下步骤。否则本批准信将被撤销，而您将有可能被遣
送回国.

Arrange a medical examination for you.

You must pass the examination to work in Singapore.
为您安排体检。
您必须通过体检才能在新加坡工作。

Apply for your Work Permit card to be issued and delivered.

申请签发并获得您的工作准证卡。

Ministry of Manpower Work Pass Division

Web http://www.mom.gov.sg Contact Us http://www.mom.gov.sg/contact Page 5 of 5
 APPLICATION FOR A WORK PERMIT

USER ID :19C9722
USER NAME :INTALENTGENT PTE. LTD.
WPNO :0 77958517 DOA :15/09/2020
COMPANY CPF SUBMISSION NO. :53142475L - PTE - 01 DATE / TIME :16 September 2020 08:43 AM

PART I PERSONAL PARTICULARS OF FOREIGN EMPLOYEE

*07795851715092020*
NAME :ZHAO HAIJIANG
DATE OF BIRTH :09/04/1991
NATIONALITY / CITIZENSHIP :CHINESE COUNTRY / REGION OF :CHINA
BIRTH
STATE / PROVINCE :HEBEI PLACE / STATE / PROVINCE :HEBEI
where the foreigner obtained his / her nationality / OF BIRTH
citizenship
MARITAL STATUS :SINGLE SEX :MALE
RACE :CHINESE RELIGION :FREE THINKER
MALAYSIAN OLD IC NO. : COLOR OF IC :
PRC IC NO. :130826199104094118 MALAYSIAN NEW IC NO. :
BANGLADESH BIRTH : FIN :G8692655K
REGISTRATION NO.
TRAVEL DOCUMENT NO. :E15619651 TRAVEL DOCUMENT TYPE :PASSPORT
TRAVEL DOCUMENT EXPIRY :05/05/2023 ENDORSEMENT TYPE :NOT IN SINGAPORE
DATE
EDUC :SECONDARY 3
YEARS OF WORKING EXP :5 YEARS & ABOVE NAME OF INSTITUTION :HE BEI SHENG CHENG DE
SECONDARY SCHOOL
EXPIRY DATE OF LTVP :
CATEGORY OF WORKER'S : IS WORKER PREVIOUSLY A :NO
LTVP / DP SINGAPORE CITIZEN OR
PERMANENT RESIDENT

PARTICULARS OF EMPLOYMENT
EMPLOYMENT STATUS :EMPLOYEE
NAME OF EMPLOYER :AL TYRES COOPERATION
OCCUPATION CODE :72312
OCCUPATION DESCRIPTION :MOTOR VEHICLE MECHANIC
BASIC MONTHLY SALARY : S$600 HOUSING PROVIDED : YES
FIXED MONTHLY ALLOWANCES : YES FIXED MONTHLY DEDUCTIONS : NO
HOUSING, AMENITIES, & SERVICES ALLOWANCES : S$250 HOUSING, AMENITIES, & SERVICES DEDUCTIONS : S$0
TRANSPORT ALLOWANCES : S$0 OTHER DEDUCTIONS : S$0
OTHER ALLOWANCES : S$0 TOTAL FIXED MONTHLY DEDUCTIONS : S$0
TOTAL FIXED MONTHLY ALLOWANCES : S$250 MONTHLY SALARY AFTER TAKING INTO ACCOUNT : S$850
FIXED MONTHLY SALARY : S$850 FIXED MONTHLY ALLOWANCES AND DEDUCTIONS
VETTING AUTHORITY : SUPPORT FROM VA? :
TRAINING DURATION :
SUPPORT AUTHORITY :

PARTICULARS OF FOREIGN EMPLOYEE'S SPOUSE

WORKER MARRIED TO SC / SPR :
NAME :
DATE OF MARRIAGE : PLACE OF MARRIAGE :
DATE OF BIRTH : NATIONALITY / CITIZENSHIP :
RESIDENTIAL STATUS : COLOR OF IC :
IC NO. (SC / SPR) : DATE OF SPR ISSUANCE :
MALAYSIAN OLD IC NO. : MALAYSIAN NEW IC NO. :
PASSPORT NO. :

FIWPS549 Page 1 of 4
WPNO : 0 77958517 DOA : 15/09/2020

PART I (A) DECLARATION BY FOREIGN EMPLOYEE

I declare that -
(a) I have read and understood the applicable conditions of work permit, as specified in the Employment of Foreign Manpower (Work
Passes) Regulations c.91A, available at www.mom.gov.sg.
(b) I have / have never* been convicted in any country/region or state of an criminal offence (if applicable, please provide details)
*Delete accordingly
(c) For the purpose of assessing this application, I consent for the Government of Singapore and its statutory authorities to obtain
from and verify information with any person, organisation or any other source, and to disclose such information to its authorised
agents. For the purpose of my employment, I also consent for the Government of Singapore and its statutory authorities to display
my employment information on the MOM’s work pass systems, and to disclose such information to any relevant person or
organisation.
(d) The information as set out in PART I is true and correct; and that all documents I have submitted in support of this application for
a Work Permit are true copies of the authentic documents.
(e) For the purposes of setting up my: (i) bank account and electronic fund transfer service account linked to the said bank account
(such as PayNow); and (ii) free Migrant Workers' Centre (MWC) membership, as part of this work permit application, I consent to
the Ministry of Manpower sending my personal particulars and work permit information to POSB and MWC.
(f) I consent to my personal data being collected, used and retained by Migrant Workers' Centre (MWC) for the purposes of
processing, administering and managing my MWC membership and my participation in MWC's programs and activities.
(g) I understand that a SingPass will help me to access Government e-services in Singapore and I give my consent to the Ministry of
Manpower to share my personal particulars with the SingPass issuing agency. This allows me to apply for a SingPass account at
a later time if I am eligible for a SingPass.
(h) I consent to the Ministry of Manpower displaying my work pass details when my work pass card is scanned using the Ministry of
Manpower's work pass mobile application.
(i) I give my consent for the Ministry of Manpower to use my contact details to contact me during emergencies and to send me
messages related to my work pass and employment in Singapore. I also consent for the Ministry of Manpower to share my
contact details with other Government agencies and statutory authorities for the same purposes.
Signature of Foreign Employee

Date: (DD-MM-YYYY)

FIWPS549 Page 2 of 4
WPNO : 0 77958517 DOA : 15/09/2020

PART II PARTICULARS OF COMPANY OR EMPLOYER

MAIN CONTRACTOR / SHIPYARD :

CPF SUBMISSION NO. OF MAIN SHIPYARD / MAIN CONTRACTOR :
NAME :AL TYRES COOPERATION
ADDRESS :150C PAYA LEBAR ROAD
SINGAPORE 409052
BUSINESS ACTIVITY :RETREADING AND VULCANISING OF TYRES

CPF SUBMISSION NO. :53142475L - PTE - 01 REGISTRATION NO. :53142475L PRIOR APPROVAL :
(ACRA) REF NO.
TELEPHONE :81025000 FAX :68412039

TEMPORARY PERMIT ISSUED AT THE TIME OF SUBMISSION? : NO

CHANGE OF EMPLOYER
IS CONSENT GIVEN FOR TRANSFER? :
NAME OF CURRENT EMPLOYER :

PART II (A) DECLARATION BY EMPLOYER

WP NO. : 0 77958517 DOA : 15/09/2020

NAME OF WORKER : ZHAO HAIJIANG
CPF SUBMISSION NO. : 53142475L - PTE - 01
NAME OF EMPLOYER : AL TYRES COOPERATION

I declare that I am authorised to bind the employer for the foreign employee named in PART I to the following -
(a) I have read and understood the applicable conditions and regulatory conditions of work permit, as specified in the
Employment of Foreign Manpower (Work Passes) Regulations c.91A, available at www.mom.gov.sg.
(b) The employer consents, for the purpose of assessing this application, for the Government of Singapore and its statutory
authorities to obtain from and verify information with any person, organisation or any other source. The employer also
consents to the disclosure of all information thereby obtained by the Government of Singapore, to statutory authorities and
authorised agents.
(c) The employer is aware that the Controller of Work Passes uses its Central Provident Fund contribution information to
determine the number of local workers employed by the employer hence determining the number of foreign employees that
it may employ. The employer has ensured that its Central Provident Fund contribution record of payments as employer
required under the Central Provident Fund Act (Cap.36) only reflects every citizen or permanent resident of Singapore who
is employed by the employer and at the appropriate contribution rate prescribed by law. The employer has made any
voluntary CPF contributions only through a separate CPF Submission Number (CSN).
(d) The employer has obtained written consent from the foreigner to apply for a Work Permit for him/her. I will produce this
consent when requested by the authority.
(e) The employer has ensured that the foreign employee fully understands the contents of PART I and that it was signed by the
foreign employee.
(f) For the purpose of setting up the foreign employee's bank account as part of this work permit application, I consent to the
Ministry of Manpower sending the employer's particulars and contact information to POSB.
(g) The employer consents to the Ministry of Manpower displaying work pass details when the foreign employee's work pass
card is scanned using the Ministry of Manpower's work pass mobile application.
(h) The employer has / has not* used the services of an Employment Agency based in Singapore for the recruitment and / or
application of a work permit for this foreign employee.
*Delete (If applicable: Employment Agency Licence No: ___________________________________. Please also ensure that the
accordingly employment agency completes PART III).
(i) The information as set out in PART II and any appeals the employer has made in relation to this application are, to the best
of my knowledge, true and correct; and that all documents submitted in support of this application and any appeals made in
relation to this application, are true copies of the authentic documents.
(j) I declare that should this application be approved, I will make an application to Ministry of Manpower to allow this foreign
employee to enter Singapore subject to prevailing entry requirements at the point of entry into Singapore.

Name of Authorised Representative:

NRIC:
Designation:
Signature:

Date: (DD-MM-YYYY)

FIWPS549 Page 3 of 4
PART III PARTICULARS OF SINGAPORE EMPLOYMENT AGENCY AND DECLARATION OF FEES PAYABLE

IS A SINGAPORE EMPLOYMENT AGENCY USED FOR THE PURPOSES OF THIS APPLICATION FOR ZHAO HAIJIANG (WP
NUMBER: 0 77958517) : YES

NAME OF SINGAPORE : INTALENTGENT PTE. LTD. LICENCE NO. : 19C9722

EMPLOYMENT AGENCY
OPERATING ADDRESS : 9 TELEPHONE : 64620087
#05-04 KALLANG PLACE
SINGAPORE 339154

FEE PAYABLE TO SINGAPORE EMPLOYMENT AGENCY

ANY FEES PAID BY THE EMPLOYEE TO THE SINGAPORE EMPLOYMENT AGENCY: YES

FEES FOR COSTS INCURRED : S$0

OVERSEAS
AGENCY FEE : S$850

PART III (A) DECLARATION BY SINGAPORE EMPLOYMENT AGENCY (applicable if the employer has used the services of a
Singapore Employment Agency.)

I declare that -

(a) I, the undersigned, am the Employment Agency personnel handling this application.
(b) I declare that I have obtained written consent from the employer and the foreigner to perform this transaction. I will produce this
consent when requested by the authority.
(c) I have explained the contents of the application and the applicable conditions and regulatory conditions of work permit, as
specified in the Employment of Foreign Manpower (Work Passes) Regulations c.91A to the foreign employee and the authorised
officer of the employer.
(d) The information as set out in this application and any appeals I have made in relation to this application is, to the best of my
knowledge, true and correct; and that all documents I have submitted in support of this application and any appeals I have made
in relation to this application, are true copies of the authentic documents.
(e) I declare that I have informed the employer of this foreign employee that should this application be approved, the employer is
required to make an application to Ministry of Manpower to allow this foreign employee to enter Singapore subject to prevailing
entry requirements at the point of entry into Singapore.

Name of Employment Agency Personnel:

Employment Agency Personnel Number:

Signature:

Date: (DD-MM-YYYY)

PART IV
TO BE COMPLETED BY CURRENT EMPLOYER IF WORK PERMIT HOLDER
NAMED ABOVE IS APPLYING FOR A CHANGE OF EMPLOYER

CONSENT TO TRANSFER FOREIGN EMPLOYEE

I, __________________________________________________ agree to release ZHAO HAIJIANG 0 77958517

(Name of Company) (Name and WP Number of Worker )
to the prospective employer AL TYRES COOPERATION
( Name of Prospective Company )

because ____________________________________________________________________________________________________.

Pending the outcome of the application, I undertake all responsibilities for the employment of the said employee and will extend his / her
work permit (if necessary). If the application is not approved and I do not wish to continue his / her employment, I will repatriate this
employee.

Name of Declarant:

NRIC:
Designation:
Signature:

Date: (DD-MM-YYYY)

FIWPS549 Page 4 of 4
FWPOL371 – Salary check

16 Sep 2020

Your salary details

Worker's name: ZHAO HAIJIANG

Work Permit no: 0 77958517

Employer's name: AL TYRES COOPERATION

Your salary declared by your employer on 15 Sep 2020 is as follows:

Salary Details

Is housing provided by employer? Yes

Basic Monthly Salary S$ 600
Add: Fixed Monthly Allowances Yes
Housing, Amenities and Services S$ 250
Transport S$ 0
Others S$ 0
Total Fixed Monthly Allowances S$ 250

Fixed Monthly Salary S$ 850

Less: Fixed Monthly Deductions No
Housing, Amenities and Services S$ 0
Others S$ 0
Total Fixed Monthly Deductions S$ 0

Monthly Salary after taking into account Fixed S$ 850

monthly allowances and deductions

Advice on salary:
• Your employer cannot pay you less than the amount declared to MOM.
• Your employer must also get your permission before reducing your salary.

Note:
• The salary details were retrieved from MOM’s records and are correct as of the date your employer
declared to MOM.
• The terms basic monthly salary, fixed monthly allowances and fixed monthly salary used above are
as defined in the Employment of Foreign Manpower (Work Passes) Regulations 2012.

This is a system generated letter. No signature is required.

Ministry of Manpower Work Pass Division

Web http://www.mom.gov.sg Contact Us http://www.mom.gov.sg/contact Page 1 of 1
 *07795851719910409*
*07795851719910409*

Casino Self-Exclusion Application Form

For Foreigners

USE BLOCK LETTERS

Personal Particulars

Name (as in Passport) Passport No

ZHAO HAIJIANG E15619651

Date of Birth (dd/mm/yyyy) FIN No (if available)

09/04/1991 G8692655K
Nationality/Citizenship Gender
CHINESE MALE
Contact Information (of Employer in Singapore – If available)

Address

150C PAYA LEBAR ROAD

SINGAPORE 409052

Contact No Email (if available)

81025000 ALTC5000@YAHOO.COM.SG

FWPOL610 Page 1 of 2
 *07795851719910409*
*07795851719910409*

Declaration for Applicant (Please Tick All Boxes)

□ I fully understand the content and purpose of this Casino Self-Exclusion application, and
that the effect of this application is that I will be excluded from entering the casinos in
Singapore. I further understand that this exclusion shall take effect immediately upon my
submission of this application to the National Council on Problem Gambling. I am also fully
aware that if I choose to enter or remain on the Casino premises after submitting the
application and take part in any gaming activities, any winnings paid or payable to me shall
be forfeited, and I will not be able to lay any claim to the said winnings.

□ I declare that this application is made voluntarily, without any force or coercion or under
any duress.

□ I understand that my application for Self-Exclusion will stay in force indefinitely, unless I
apply to revoke from NCPG after a period of at least 1 year. I also understand that NCPG
will provide my name and particulars to the relevant agencies and organizations under
Section 168(3) of the Casino Control Act to inform them of my Self-Exclusion.

□ I declare that the information provided by me in this application is true and correct and I
furnish the information knowing that I may be liable to criminal prosecution if I have stated
any information that I know to be false or do not believe to be true.

_______________ _______________
Signature Date

PLEASE COMPLETE AND SEND THIS FORM BY HAND OR BY REGISTERED MAIL

TO:

THE NATIONAL COUNCIL ON PROBLEM GAMBLING

510 THOMSON ROAD
#05-01
SLF BUILDING
SINGAPORE 298135

For Administrative Use only

Date / Time Signature

Received by:

Processed by:

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