INSTITUT PENYELIDIKAN DAN KEMAJUAN PERTANIAN MALAYSIA

MALAYSIAN AGRICULTURAL RESEARCH AND DEVELOPMENT INSTITUTE

http://www.mardi.gov.my

BORANG PERMOHONAN LATIHAN INDUSTRI

(INDUSTRIAL TRAINING APPLICATION FORM)

SILA LEKATKAN
GAMBAR
UKURAN PASPOT
(PLEASE PASTE
YOUR PASSPORT
PHOTO)

A. MAKLUMAT PERIBADI (PERSONAL INFORMATION)

NAMA PELAJAR (STUDENT
NAME)

NO KP (IC NO)

NO PELAJAR (STUDENT ID)

JANTINA (GENDER)

KEWARGANEGARAAN
(NATIONALITY)

ALAMAT (ADDRESS)

NO HP /
(HP NO)

PERHUBUNGAN (CONTACT)

EMAIL (EMAIL)

B. MAKLUMAT PENGAJIAN (STUDIES INFORMATION)

NAMA INSTITUSI (INSTITUTIONAL)

STATUS UNIVERSITI (UNIVERSITY

STATUS)

UNIVERSITI AWAM (PUBLIC UNIVERSITY)

*Sila pilih (Please tick ())

LAIN-LAIN (NYATAKAN) (OTHERS

(SPECIFY)

PERINGKAT PENGAJIAN
(EDUCATION LEVE)L

SIJIL (CERTIFICATE)

DIPLOMA

*Sila pilih (Please tick ())

IJAZAH (BACHELOR)

IJAZAH SARJANA (MASTERS)

BIDANG PENGAJIAN (FIELD OF

STUDY)

PENGKHUSUSAN
(MAJORING)

PILIHAN TEMPAT
LATIHAN
(PLACEMENT)

TEMPOH LATIHAN INDUSTRI

(INDUSTRIAL TRAINING PERIOD)

UNIVERSITI SWASTA (PRIVATE

UNIVERSITY)

Sertakan salinan transkrip peperiksaan (Enclose examination transcripts)

C. PENGESAHAN PELAJAR / STUDENT VERIFICATION

Saya sahkan bahawa maklumat yang diberikan adalah benar dan saya bersetuju sekiranya maklumat yang diberikan bercanggah
saya boleh dikeluarkan daripada menjalani Latihan Industri di MARDI (I certify that the information given is correct and agreed to
be removed from the industrial training if I had given the false statement)

Tandatangan Pelajar (Student Signature)

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Tandatangan Penyelaras Latihan Industri (Industrial Training

Coordinator Signature)
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Nama / Name:

Nama / Name:

No. Pelajar /
Student ID:

Cop Jabatan /
University Official
seal:

Tarikh / Date:

Tarikh / Date