UKM/PPPS/C/P03/AK06/01

Tarikh Kuatkuasa 01-03-2016

PUSAT PENGURUSAN AKADEMIK

PERMOHONAN PENANGGUHAN PENGAJIAN
Centre for Academic Management
Application for Study Deferment

Bahagian A: Maklumat Diri Pelajar

Part A: Student’s Detail

Nama (Name)

No. Pendaftaran
(Registration Number)
No. Telefon
(Telephone Number)

Email (E-mail)

Fakulti / Institut
(Faculty / Institute)
Program Pengajian Sarjana Doktor Falsafah
(Program) (Masters) (Doctor of Philosophy)
Bentuk Pendaftaran Sepenuh Masa Separuh Masa
(Type of registration) (Full Time) (Part Time)

Pusat Pengajian/Jabatan : ____________________________________________________

(School / Department)

Sejarah menangguh (Jika Ada) : Semester__________ Sesi (Session)__________

(Deferment history) (if any)
Semester__________ Sesi (Session)__________

Semester__________ Sesi (Session)__________

Semester__________ Sesi (Session)__________

Semester__________ Sesi (Session)__________

Sebab-sebab permohonan (Reason) :

_____________________________________________________________________________________
_

_____________________________________________________________________________________
_

Tandatangan : ________________ Tarikh : _______________

(Singature) (Date)
 UKM/PPPS/C/P03/AK06/01
Tarikh Kuatkuasa 01-03-2016
Bahagian B: Perakuan Penyelia /Penyelaras Program
(Part B : Approval from supervisor / program coordinator)

Permohonan : Disokong (Agree) / Tidak disokong (Disagree)

Ulasan : ______________________________________________________________________________

______________________________________________________________________________________

Tandatangan : ________________ Tarikh : _______________

(Singature) (Date)
[*Potong yang tidak berkenaan]

Part C: Remarks from the international student centre

(for international students only)

Approved / Not approved*

Additional remarks: ____________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Signature : ____________________ Date : _________________

Name & official stamp : ______________________

Bahagian D : Kelulusan Fakulti / Institut

(Part D : Approval from Faculty / Institute)

Permohonan : Diluluskan (Approve) / Tidak diluluskan (Not Approve)

Tandatangan : ____________________ Tarikh : _________________

(Singature) (Date)

Nama : ________________________________

[*Potong yang tidak berkenaan]