(Form Reference No)

Gambar Bersaiz
Passport

BORANG PERMOHONAN MENGIKUTI PROGRAM PROFESIONAL/EKSEKUTIF

(APPLICATION FORM FOR PROFESSIONAL/EXECUTIVE PROGRAMME)

1. PROGRAM YANG DIPOHON (DETAILS OF PROGRAMME APPLIED)

Nama Program (Name of Programme)

Pengkhususan (Specialisation)

Cawangan Pusat Pembelajaran

2. BUTIRAN PERIBADI PEMOHON (APPLICANT’S PERSONAL DATA)

Nama Penuh

No. Kad Pengenalan (Identity Card No.) Umur (Age)

- -

Tarikh Lahir (Date of Birth) Jantina (Gender)

/ /

Negeri Lahir (State of Birth) Warganegara (Citizenship)

Taraf Perkahwinan (Marital Status)

Alamat Surat Menyurat (Mailing Address)

Poskod (Postcode) Bandar (Town)

Negeri (State) Negara (Country)

No. Telefon Rumah (Home Phone No.) No. Telefon Pejabat (Office Phone No.)

No. Telefon Bimbit (Hand Phone No.) Nombor Faksimili (Fax No.)

E-Mel (Email)

3. BUTIRAN PEKERJAAN / PENGALAMAN KERJA (EMPLOYMENT DETAILS / EXPERIENCE)

Tempoh Jawatan
Jawatan (Working Period) Nama & Alamat Majikan Tanggungjawab
(Position) Dari Hingga (Employer’s Name and Address) (Responsibility)
(From) (To)
 4. LATAR BELAKANG AKADEMIK (ACADEMIC BACKGROUND)

Tahun Tahun
NO Universiti/Institusi Gred Pengkh susan
Masuk Keluar
(No,) (University/Instituition) (CGPA/PNGK) (Majoring)
(Year In) (Year Out)

5. BANTUAN KEWANGAN (FINANCIAL SUPPORT)

Sendiri Majikan Lain-lain Penaja

(Self) (Employer) (Others Sponsor)

Jika mendapat penajaan daripada mana-mana penaja, sila kemukan surat penajaan.
(If sponsored by any organization, please attach a letter of gurantee from sponsor.)

6. PENGAKUAN (DECLARATION)

Saya mengaku bahawa keterangan yang diberikan di atas adalah benar dan semua salinan sijil dan surat
akuan yang disertakan bagi menyokong permohonan ini adalah disahkan seperti dikehendaki. Saya akui
bahawa pihak Universiti berhak menolak permohonan atau menarik kembali tawaran pada bila-bila masa
sekiranya mana-mana keterangan atau salinan yang dikemukakan adalah tidak benar.
(I certify that information I have given in this application is correct. I agree that the University can withdraw the
offer or terminate my study if any information given is incorrect. I also undertake full responsibility of any fees
and liabilities.)

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Tandatangan (Signature) Tarikh (Date)
UNTUK KEGUNAAN PEJABAT (FOR OFFICE USE ONLY)

Keputusan Jawatankuasa Tetap Senat (Pengajian Berterusan)

University Senate Standing Committee (Continuing Education) Approval

Disokong Ditolak Lain-lain

(Approved) (Rejected) (Others)

Ulasan Pengerusi (Comments of Chairman)

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Tandatangan Pengerusi (Chairman’s Signature) Tarikh (Date)