Anda di halaman 1dari 2

UKM/PPPS/C/P03/AK09

Tarikh Kuatkuasa 01-03-2010

PUSAT KEMBANGAN PENDIDIKAN


PERMOHONAN TAMBAH MASA PENGAJIAN
Centre for Graduate Management
Application for Study Extension

Bahagian A: Maklumat Diri Pelajar


Part A: Students Details

Nama (Name)
No. Pendaftaran
(Registration
Num
Alamat tetap
(Permanent Address)
No. Telefon
(Telephone number)
Alamat surat menyurat
(Correspondence address)
No. Telefon
Waris/Jiran/Kawan
(Telephone number of nextof-kin/friends/neighbour)
No. Faksimili
(Fax. No.)
Emel (E-mail)
Program pengajian (Program)
:
Bentuk pendaftaran(Type of registration) :

Sarjana / Doktor Falsafah* (Masters / Doctor of Philosophy)


Sepenuh Masa / Separuh Masa* (Full time / Part time)

Pusat pengajian/Jabatan
(School/Department)
Fakulti (Faculty)

______________________________________________

______________________________________________

Sesi diterima mengikuti program (Date of registration):

Semester ________

Sesi (Session) ________

Tarikh jangka tamat (Expected date to complete studies):

Semester ________

Sesi (Session) ________

Tarikh permohonan tambah masa (Date applied for extension):Semester ________


Sebab-sebab memohon (Reasons to extend):

Sesi (Session) ________

_______________________________________________

_______________________________________________________________________________________
Pernah / Tidak pernah* memohon tambah masa pengajian?(Have you applied to extend semesters before?)
Jika Pernah (if yes, semester(s) approved)

Semester ________

Sesi (Session) ________

Semester ________

Sesi (Session) ________

Tandatangan (Signature) : _________________


[*Potong yang tidak berkenaan(Delete where not applicable)]

Tarikh (Date) : ___________

UKM/PPPS/C/P03/AK09
Tarikh Kuatkuasa 01-03-2010
Bahagian B:

Perakuan Penyelia (Part B: Approval from Supervisor)

Permohonan: Disokong/ Tidak disokong*


Laporan Tahap Pencapaian Calon (sila lampirkan Laporan Prestasi Calon)
________________________________________________________________________________
________________________________________________________________________________
_________________________________________________________________________________________

Tandatangan

: ___________________________

Tarikh : _______________________

Nama

: _______________________________________________

Bahagian C:
Perakuan Pengerusi Pusat Pengajian / Ketua Jabatan
(Part C: Approval from Chair of School/Head of Department)
Permohonan: Disokong/ Tidak disokong*

Tandatangan

: ___________________________

Tarikh : _______________________

Nama

: _______________________________________________

Bahagian D:

Perakuan Dekan Fakulti (Part D: Approval from the Dean of Faculty)

Permohonan: Disokong/ Tidak disokong*

Tandatangan

: ___________________________

Nama

: _______________________________________________

[*Potong yang tidak berkenaan]

*MERAH/RED (Rujukan PPS sahaja/Office use only)

Tarikh : _______________________