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UKM-SPKP-PHA-PK03-BO01 No. Semakan: 00 Tarikh Kuatkuasa: 01/05/2014

BORANG PERMOHONAN PAS

APPLICATION OF PASS

Catatan: Borang ini hendaklah ditulis. Tandakan (X) dalam petak yang berkenaan.

Note: This form should be written. Mark (X) in the appropriate box.

Jenis Permohonan Type of Application

Pelajar

Tanggungan

Student Dependant

A. MAKLUMAT PELAJAR PARTICULARS OF STUDENT

Nama Name

No. Pasport Passport No.

Warganegara

Nationality

Jantina Gender

Lelaki Male

Perempuan Female

No. Matrik Matric No.

Jenis Pengajian Type of Study

Sepenuh Masa Full time

Separuh Masa Part time

Program Pengajian Program Study

Doktor Falsafah Ph.D

Sarjana Master

Diploma Siswazah Graduate Diploma

Fakulti Faculty

Tarikh Pendaftaran Date of Registration

Tempoh Tamat Pengajian Expected Semester of Completion

Alamat di Malaysia Address in Malaysia

No. Telefon Telephone No.

Emel Email

Tandatangan: Signature

Tarikh:

Date

B. MAKLUMAT TANGGUNGAN PARTICULARS OF DEPENDANT

Nama Name

No. Pasport Passport No.

Warganegara

Nationality

Jantina Gender

Lelaki Male

Perempuan Female

Hubungan Relationship

C. KEGUNAAN PEJABAT FOR OFFICE USE ONLY

Cop Rasmi dan Tandatangan: Official Stamp and Signature

Tarikh:

Date

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UKM-SPKP-PHA-PK03-BO01 No. Semakan: 00 Tarikh Kuatkuasa: 01/05/2014

BORANG PERMOHONAN PAS

APPLICATION OF PASS

SENARAI SEMAK PERMOHONAN APPLICATION CHECKLIST

A. Permohonan Pas Pelajar Application of Student Pass

I. Permohonan perlu dibuat 2 MINGGU sebelum tarikh tamat Visa.

Application must be made 2 WEEKS before the expiry of the Visa.

II. Sila kemukakan dokumen-dokumen berikut semasa permohonan dibuat:

Please submit all the following documents during the application:

Bil. No.

Dokumen Yang Diperlukan Required Document

Salinan No. of Copy

Tanda ()

Tick ()

1 Borang Permohonan Pas (UKM-SPKP-PHA-PK03-BO01) Student Pass Application Form (UKM-SPKP-PHA-PK03-BO01)

4

2 Slip Pendaftaran Registration Slip

4

3 Resit Pembayaran Yuran Pengajian Tuition Fees Receipt of Payment

4

4 Surat Tawaran dari UKM Offer Letter from UKM

4

5 Surat Tamat Pengajian dari Universiti/Kolej terdahulu Release Letter from Previous University/College

4

6 Salinan Pasport (Setiap muka surat) Copy of Passport (Whole Pages)

4

7 Sijil dan Transkrip Akademic Sarjana atau Sarjana Muda Certificate and Transcript of Master Degree or Bachelor Degree

4

8 Surat Berhenti Kerja dari majikan terdahulu (Jika berkaitan) Resignation Letter from previous employer(If applicable)

4

9 Pemeriksaan Kesihatan (Pengesahan dari Pusat Kesihatan UKM) Health Examination (Endorsed by UKM Medical Centre)

4

10 Gambar berukuran pasport (Latar belakang biru) Passport size photo (Blue background)

4

11 Borang Imigresen IM.14 Completed Immigration Form IM.14

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B. Permohonan Pas Untuk Tanggungan Application of Dependant Pass

I. Permohonan hendaklah dibuat sebaik sahaja ketibaan ahli keluarga di Malaysia. Application must be made as soon as the arrival of family members in Malaysia.

II. Sila kemukakan dokumen-dokumen seperti jadual di bawah semasa permohonan dibuat.

Please submit the documents as per the schedule below during the application.

III. Senarai semak berikut adalah untuk SATU PASPORT AHLI KELUARGA sahaja. Setiap satu pemegang pasport memerlukan jumlah salinan dokumen yang sama. This checklist is for ONE FAMILY PASSPORT application. Additional of other family passport will require the same

number of copies.

Bil. No.

Dokumen Yang Diperlukan Required Document

Salinan No. of Copy

Tanda ()

Tick ()

1 Borang Permohonan Pas (UKM-SPKP-PHA-PK03-BO01) Student Pass Application Form (UKM-SPKP-PHA-PK03-BO01)

3

2 Surat Pengesahan Keluarga dari Kedutaan ATAU Sijil Perkahwinan ATAU Sijil Lahir Family Letter from the Embassy OR Marriage Certificate OR Birth Certificate

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3 Pasport Keluarga dan Visa Semasa (Setiap Muka Surat) Family Passport and Current Visa (Whole Pages)

3

4 Pasport Pelajar dan Visa Semasa (Setiap Muka Surat) Student Passport and Current Visa (Whole Pages)

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5 Insuran Perubatan sekurang-kurangnya sah untuk satu tahun atau lebih (Kad Insurans / Polisi Insurans / Resit Pembayaran) Medical Insurance at least

one year or more validity (Insurance Card/Insurance Policy/ Payment Receipt) 3

6 Gambar berukuran pasport (Latar belakang biru) Passport size photo (Blue background)

3

7 Borang Imigresen IM.12 Completed Immigration Form IM.12

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