PGDT HPGD4606

FORM A

PRACTICUM PLACEMENT INFORMATION (PGDT)

Student’s Name :
Matriculation No :

H/Phone No. & Email address :

OUM Learning Centre :

**Practicum mode

**Students under Mode 1 and Mode 2 must enclose a copy of certified letters/documents to prove teaching
experience in the related field.

INSTITUTION INFORMATION

Name of School/College/University
:

Full Address
:

Contact person & Phone no

:

Date of practicum commencement :

MANAGEMENT CONFIRMATION (PRINCIPAL/HEAD/DEAN/etc)

Signature & Stamp :

Name :

Date :

Remarks :

Note:

Please scan & email this form BEFORE commencing your practicum session to:

Email: nooruzaila@oum.edu.my OR

Fax no: 03-78030745 (attn: Pn.Nooruzaila Abd Rashid)