BORANG PERMOHONAN (Application Form)

DUTA SISWAZAH (Graduate Ambassador)

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PASSPORT
PHOTOGRAPH
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BAHAGIAN A (PART A) : BUTIRAN PEMOHON (APPLICANT DETAILS)

Nama (Huruf besar)
:
Name (Capital letter):
No. matrik Fakulti/Institut
: :
Matric no. Faculty/Institute

Alamat semasa
:
Current address

No. kad pengenalan / No. pasport

:
Identity card no. / Passport no.

Mel-e Tarikh lahir

: :
E-mail Date of birth

No. telefon No. Telefon bimbit

: :
Telephone no. Mobile phone no.

Jantina Lelaki Perempuan Warganegara

: :
sex Male Female Nationality

Status perkahwinan Bujang Berkahwin Agama

: :
Marital status Single Married Religion

Jenis program Doktor Falsafah Bilangan semester mendaftar, Nyatakan

:
Type of programme Doctor of Philosophy Total semesters registered, Please state

Sarjana Bilangan semester mendaftar, Nyatakan

:
Masters Total semesters registered, Please state

Tesis
Jenis pengajian Kerja kursus Kerja kursus dan tesis sahaja
:
Type of study Course work Course work and thesis Thesis
Only

BAHAGIAN B (PART B): MAKLUMAT AKADEMIK PEMOHON (APPLICANT ACADEMIC INFORMATION)

PNGK Ijazah Pertama^ : PNGK Ijazah Kedua/ Sarjana^ :

First Degree CGPA Second Degree / Masters CGPA
* Jika berkenaan (if applicable)
BAHAGIAN C (PART C): SUMBANGAN/KHIDMAT BAKTI PEMOHON (Applicant Contribution)
Sila lampirkan dokumen berkaitan untuk tujuan pembuktian(Attach a copy of related documents for evidence)

BIL PERANAN (Role)/AKTIVITI (Activities) TAHUN PERINGKAT (Level)

(YEAR)

BAHAGIAN D (PART D) :

Kenapa anda berminat untuk menjadi DUTA SISWAZAH? (tidak melebihi 20 patah perkataan)
Why you are interested to become POSTGRADUATE AMBASSADOR? (not more than 20 words)

BAHAGIAN E (PART E): PERAKUAN (Verification)

I. PERAKUAN PENYELIA (Supervisor verification)

PERMOHONAN INI DISOKONG / TIDAK DISOKONG (This application is recommended/not recommend)

Ulasan/Comment :___________________________________________________________________________

_____________________________________________ ________________________
Tandatangan Penyelia (Supervisor’s Signature) Tarikh (Date) :

II. PERAKUAN PELAJAR (Student verification)

Saya akui bahawa maklumat yang diberi adalah benar. Sekiranya maklumat ini didapati palsu, pihak Universiti
berhak menolak permohonan ini.

I, hereby declare that all the information given is true. If it is found not true, the University has right to eliminate my
application.

_____________________________________________ ________________________
Tandatangan Pemohon (Applicant’s Signature) Tarikh (Date) :

KEGUNAAN PEJABAT / FOR OFFICE USE - PUSAT SISWAZAH

Status pendaftaran Daftar Tidak daftar Tarikh terima

:
Registration status Register Not register Date accepted

DITERIMA OLEH PEGAWAI PUSAT SISWAZAH

(Accepted by the Officer of Graduate Centre)

Catatan (Remarks) :

___________________________
Tandatangan (Signature)
Tarikh (Date) : Stamp