FORM A

COMPLETION OF STUDY REPORT FORM (FOR PETRONAS SPONSORED STUDENT IN UTP)

1. STUDENT PARTICULARS
NAME : ___________________________________________________________________________

STUDENT NO : _________________________ IC NO. / PASSPORT NO.: ______________________

CORRESPONDENCE ADDRESS : ___________________________________________________________________________

___________________________________________________________________________

EMAIL ADDRESS : ___________________________________________________________________________

TEL. NO. : HOME _________________________ MOBILE _________________________

2. EMERGENCY CONTACT DETAILS

NAME : ___________________________________________________________________________

CORRESPONDENCE ADDRESS : ___________________________________________________________________________

___________________________________________________________________________

TEL. NO. : HOME _________________________ MOBILE _________________________

3. ACADEMIC PARTICULARS

STUDY COMMENCEMENT DATE : ____________________ STUDY COMPLETION DATE : _________________________

COURSE / PROGRAMME (UG/PG): __________________________________________________________________________

4. INTERVIEW DETAILS / PETRONAS ENTRY LEVEL ASSESSMENT

a. HAVE YOU BEEN INTERVIEWED ? (please tick one ) YES NO

IF YES, PLEASE STATE: INTERVIEW LOCATION : _________________________________________________________

INTERVIEW DATE : _________________________

b. DID YOU SUBMIT THE DECLARATION FORM DURING INTERVIEW? YES NO

c. EARLIEST DATE FOR COMMENCEMENT OF WORK : _________________________

5. DECLARATION

1) I DO HEREBY DECLARE THAT THE INFORMATION PROVIDED ABOVE IS ACCURATE AND TRUE ; AND
2) I FURTHER AGREE AND ACCEPT THAT PETRONAS WILL BE ENTITLED TO TAKE ANY ACTION AGAINST ME IN THE EVENT
SUCH INFORMATION PROVIDED BY ME IN 5(1) HEREINABOVE IS FOUND TO BE FALSE OR INACCURATE; AND
3) I FURTHER EXPRESSLY AGREE AND DO IRREVOCABLY AUTHORISE PETRONAS AND/OR ITS NOMINEE OR NOMINEES TO
DISCLOSE THE INFORMATION ABOVE TO ANY OTHER THIRD PARTY(IES) FOR THE PURPOSES OF POTENTIAL EMPLOYMENT
AND I FURTHER AGREE DECLARE COVENANT AND UNDERTAKE THAT I WILL INDEMNIFY AND KEEP PETRONAS FULLY
INDEMNIFIED IN THE EVENT OF ANY CLAIMS FOR LOSS OR DAMAGES OF ANY NATURE WHATSOEVER ARISING OUT OF THE
DISCLOSURE OF SUCH INFORMATION ; AND
4) I FURTHER EXPRESSLY AGREE AND IRREVOCABLY AUTHORISE UNIVERSITY TEKNOLOGI PETRONAS (UTP) TO RELEASE
SUCH INFORMATION INCLUDING MY ACADEMIC RESULTS TO PETRONAS AND/OR ITS NOMINEE OR NOMINEES; AND
5) SUBJECT TO THE PROVISION, UNDER THE AGREEMENT, I FURTHER AGREE THAT THE EFFECTIVE DATE OF MY REPORTING
SHALL COMMENCE UPON RECEIPT BY PETRONAS OF MY FINAL ACADEMIC RESULTS.

SIGNATURE : _________________________ DATE : ________________________

FOR OFFICE (ESU) USE ONLY

DATE REPORTED : ______________________ FINAL STATUS :

STUDENT FINAL RESULT / CGPA : ______________________ ACCEPT

ESMS STATUS : CHANGE FROM _______ TO ______ REJECT

REMARKS :
___________________________________
DESK OFFICER
EDUCATION SPONSORSHIP UNIT
DATE :

ESU/FORMA/DEC2010-UTP