UNISEL-BC00-F001

INDUSTRIAL TRAINING PROGRAMME

STUDENT PERSONAL DETAILS
PART A: STUDENT INFORMATION
NAME: .........................................................................................................................................................................
MATRIC NO : .................................................... NRIC / PASSPORT: .
DATE OF BIRTH: ............................................ PLACE OF BIRTH: ...................
FACULTY: .
PROGRAMME: .
MAJORING FIELD: ... *if any
LATEST CGPA: TOTAL CREDIT HOUR: .
DURATION OF INDUSTRIAL TRAINING: . TO: ..
PRACTICAL SESSION : PRACTICAL SEMESTER:
EMAIL : ..
CORRESPONDENCE ADDRESS: ...
..
..
PHONE NO: (HOUSE)

. (MOBILE)

HOME ADDRESS: .
...
...
PHONE NO: (HOUSE) .... (MOBILE)
STATE OF ORIGIN: ...

PART B: STUDENT SIGNATURE

I hereby certify the above information is true

(
)
Date:

PART C: ACCEPTANCE
Supported by:
Industrial Training Coordinator
Received by:
Business, Research, Industrial
Linkages & Consultancy (BRIC)

Date:

Sign:

Date:

Sign:
Revised: 20214

________________________________________________________________________________________________
Centre for Business, Research, Industrial Linkages & Consultancy (BRIC)
Universiti Selangor, 4th Floor, Satellite Building, Jalan Zirkon A7/A, Seksyen 7
40000 Shah Alam, Selangor Darul Ehsan.
T: 03-5522 3511 F: 03-5522 3441
E: bric@unisel.edu.my