_____________________________________________
Programme
_____________________________________________
Student Name
_____________________________________________
Matric Number
_____________________________________________
Date
_____________________________________________
Organization Name
_____________________________________________
Organization Address
_____________________________________________
_____________________________________________
Duration
___________________
Until ___________________
_____________________________________________
Designation
_____________________________________________
Department
_____________________________________________
E-mail Address
_____________________________________________
Phone Number
_____________________________________________
Companys Name
_____________________________________________
RM__________________________________________
__________________________
(Signature Company Supervisor)
Date : ____________________
Note : Company Supervisor please fax or post this form directly to the following address on or before end of first
week of reporting duty by the student.
_________________________________________________________________________________________________
Center for Business, Consultancy & Industrial Linkages (BCI), Universiti Industri Selangor
Jalan Zirkon A 7/A, Seksyen 7, 40000 Shah Alam, Selangor Darul Ehsan
Tel : 03-5522 3511/5522 3400 faks : 03-5522 3441
http://www.bci.unisel.edu.my