Appendix 10

KUPTM.PHEA.CAES.LI.08-00

STUDENT’S PARTICULARS FORM

PHOTO
INSTRUCTION
1. This form is used to get student’s information for practicum purposes.
2. It is to be completed by the student before the practicum starts.
3. This form MUST be submitted to the Industrial Training Coordinator before the practicum starts.

Name of School: _______________________________

PERSONAL DETAILS

Full Name

Gender F/M

IC No. ID No.

Race Religion

Date of Birth Place of Birth

Phone No. (House) Phone No. (Mobile)

Permanent Address

Current Address

Marital Status Health Problem: Yes (Please State if

Yes)

FAMILY DETAILS

Father’s Name

Age

Phone No.

Occupation

Mother’s Name

Age

Phone No.
Occupation

Name of Guardian

Age

Phone No.

Occupation

Address

I hereby declare that the details given are true.

Signature ____________________ Date _______

Name _____________________________________