UNIT PERUMAHAN PELAJAR (UPP)

(Student Housing Unit)

PERMOHONAN TINGGAL DI KOLEJ KEDIAMAN

(Application For Accommodation)

1.

Nama
(Name)
Jantina
(Gender)
Thn. Pengajian
(Year of Study)
Fakulti
(Faculty)
Kolej Yang Dimohon

Alamat E-mel
(E-mail Address)
Alamat Semasa
(Current Address)

10. Sebab/Alasan Memohon

(Reason/s to Apply)

2.
4.
6.
7.
8.
9.

:
:

3. No. Matrik
(Matric #)
5. No. Telefon Bimbit
(Mobile #)

:
:

(Proposed Residential College)

Nota: Jika disebabkan kesihatan, sila lampirkan bersama surat/sijil sakit dari klinik UKM atau mana-mana klinik
Note: For health reason, please attach medical letter/certificate from UKM or other clinic
Tandatangan Pemohon
(Applicants Signature)

Tarikh
(Date)

UNTUK KEGUNAAN PEJABAT

(FOR OFFICE USE ONLY)
Kelulusan
(Approval)
LULUS
(Approved)

Tandatangan Pengetua
(Residential College Master Signature)

TIDAK DILULUS
(Not Approved/Decline)

Tarikh
(Date)