LAMPIRAN A

No. Semakan: 00 Tarikh Kuatkuasa:01/12/2019

BORANG PERMOHONAN BIASISWA NAIB CANSELOR UKM

UKM VICE-CHANCELLOR SCHOLARSHIP APPLICATION FORM

PERMOHONAN HENDAKLAH DISERTAKAN BERSAMA DOKUMEN SEPERTI BERIKUT:

THE FOLLOWING DOCUMENTS MUST BE ATTACHED TO APPLICATION:

TANDAKAN (√)
PLEASE TICK (√)
BIL DOKUMEN
Pusat Siswazah
NO DOCUMENT PEMOHON
Graduate
APPLICANT
Centre
1 keping gambar berukuran pasport
1.
1 passport sized photograph
Salinan Kad Pengenalan/Pasport (disahkan benar dari
2. salinan asal)
Copy of Identity card/Passport (certified true copy)
Salinan Transkrip Akademik Sarjana Muda dan Sarjana
(disahkan benar dari salinan asal)
3.
Certificate copies of academic transcripts Bachelor Degree
and Master Degree (certified true copy)
Muka hadapan artikel yang telah diterbitkan
4.
Front page of the published articles
Muka hadapan permohonan kemasukan ke UKM secara atas
5. talian
Front page of the UKM online Application Form
Cadangan penyelidikan
6
Research proposal
Huraikan secara ringkas mengapa UKM perlu memilih anda
untuk biasiswa ini
7.
Briefly describe why UKM should choose you for this
scholarship
8. Curriculum Vitae

Borang yang telah lengkap diisi serta dokumen yang diperlukan hendaklah dihantar kepada:
Completed form and required documents must be submitted to :

Pengarah / Director
Pusat Siswazah UKM/ The UKM Graduate Centre
Universiti Kebangsaan Malaysia
43600 UKM Bangi, Selangor Darul Ehsan,
Malaysia.
e-mail: awardsandscholarship@ukm.edu.my

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 LAMPIRAN A
No. Semakan: 00 Tarikh Kuatkuasa:01/12/2019

BORANG PERMOHONAN BIASISWA NAIB CANSELOR UKM

UKM VICE-CHANCELLOR SCHOLARSHIP APPLICATION FORM

BAHAGIAN A / SECTION A :
BUTIRAN DIRI PEMOHON / PERSONAL INFORMATION OF APPLICANT

Nama (dalam huruf besar) / Name (in capital letters) :

Tarikh Lahir : No. Matrik :

Date of Birth Matric No

No. Kad Pengenalan / Pasport : Umur :

Identity Card No. / Passport No. Age

Warganegara : Jantina :
Nationality Gender

Negara Asal :
Origin Country

Taraf perkahwinan : Bujang Berkahwin

Maritial status Single Married

Fakulti : Jabatan :
Faculty Department

Sesi/Semester yang Dipohon:

Session/Semester Applied for
eg: 2020/2021 (Semester 1)

Jenis Program : Doktor Falsafah Sarjana Jenis Pengajian :

Programmes Doctor of Master Type of study

Bidang pengajian : Tempoh pengajian :

Field of study Duration of Study

Nama Penyelia (jika ada) :

Supervisor (if any)

Tajaan lain (jika ada) :

Sponsorship (if any)

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 LAMPIRAN A
No. Semakan: 00 Tarikh Kuatkuasa:01/12/2019

BORANG PERMOHONAN BIASISWA NAIB CANSELOR UKM

UKM VICE-CHANCELLOR SCHOLARSHIP APPLICATION FORM

Alamat :
Address

Poskod : Negeri :
Postcode State

No. Telefon :
Telephone No.

Emel :
Email

BAHAGIAN B/ SECTION B :
BUTIRAN KULULUSAN AKADEMIK / ACADEMIC QUALIFICATION

Butiran Sarjana Muda Sarjana

Information Bachelor Master

Nama Ijazah
Name of Degree

Kelas/PNGK
Class/CGPA

Bidang
Specialization

Tahun
Year

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 LAMPIRAN A
No. Semakan: 00 Tarikh Kuatkuasa:01/12/2019

BORANG PERMOHONAN BIASISWA NAIB CANSELOR UKM

UKM VICE-CHANCELLOR SCHOLARSHIP APPLICATION FORM

Nama Universiti
Name of the University

BAHAGIAN C/ SECTION C :
SENARAI PENERBITAN / LIST OF PUBLICATIONS
1. Artikel Jurnal/ Journal Articles

Bil Pengarang/ Authors Tajuk/ Title Maklumat Jurnal/ Journal Faktor Impak
No Information Wos Dan Kuartil
(Nama Jurnal, Nombor Jilid Jurnal/ Wos
& Halaman/ Journal Name, Impact Factor
Volume Number & Page And Journal
Number) Quartile

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 LAMPIRAN A
No. Semakan: 00 Tarikh Kuatkuasa:01/12/2019

BORANG PERMOHONAN BIASISWA NAIB CANSELOR UKM

UKM VICE-CHANCELLOR SCHOLARSHIP APPLICATION FORM

2. Lain-Lain Penerbitan/ Other Publications

BAHAGIAN D / SECTION D :
PENGADIL AKADEMIK / ACADEMIC REFEREES

SENARAIKAN DUA (2) PENGADIL AKADEMIK

LIST TWO (2) OF ACADEMIC REFEREES

Senaraikan dua (2) pengadil akademik untuk menyokong permohonan anda

Provide two (2) academic referees to support your application

Nama: Nama:
Name Name
Jawatan: Jawatan:
Position Position
Alamat: Alamat:
Address Address
No. Telefon: No. Telefon:
Telephone No. Telephone No.
Alamat Emel: Alamat Emel:
Email Address Email Address

BAHAGIAN E / SECTION E :
PERAKUAN DAN PENGESAHAN PEMOHON
DECLARATION AND CONFIRMATION BY APPLICANT

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 LAMPIRAN A
No. Semakan: 00 Tarikh Kuatkuasa:01/12/2019

BORANG PERMOHONAN BIASISWA NAIB CANSELOR UKM

UKM VICE-CHANCELLOR SCHOLARSHIP APPLICATION FORM

PERAKUAN PELAJAR/ APPLICANT DECLARATION

Saya akui telah membaca dan memahami semua maklumat dan dokumentasi yang dimuatkan dalam
borang permohonan dalam pengetahuan saya adalah benar dan lengkap. Saya faham bahawa sebarang
maklumat yang didapati palsu akan menyebabkan permohonan ini ditolak. Jika saya ditawarkan dan
diterima dalam Biasiswa Naib Canselor UKM ini, saya bersetuju mematuhi peraturan Universiti
Kebangsaan Malaysia.

I, the undersigned, declare that I have read and understand that all information and documentation
provided in the application are, to the best of my knowledge, correct and complete. I understand that any
false statement or omission, even if unintended on my part may result a rejection of my application. Finally,
if I am offered and accepted to enroll in the UKM Vice-Chancellor Scholarship Fund, I agree to abide by the
rules and regulations of University.

Tandatangan Pemohon / Applicant Signature: Tarikh / Date:

Tamat / End

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