borang pertukaran kolej transfer of college form · pdf fileborang pertukaran kolej transfer...
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NO. SEMAKAN : 03 NO. ISU : 02 TARIKH KUATKUASA : 30/04/2013 1/2
OPERASI PERKHIDMATAN SOKONGAN
KOLEJ-KOLEJ Kod Dokumen: OPR/KOLEJ/BR02/PEN003
BORANG PERTUKARAN KOLEJ Transfer of College Form
(Diisi dalam 2 salinan/To be filled in 2 copies)
Semester Semasa/Current Semester: 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12 (Sila bulatkan/Please circle) Sesi Semasa/Current Session :_________________
Kolej Semasa: ……………………………… No Bilik: …………………........ Kolej Yang Dipohon :…………………………............................. Current College Room No. College Applied For
A. BUTIR-BUTIR DIRI (PERSONAL INFORMATION)
Nama/Name : ……………………………………………………………………………………................ No. Matrik/Matric No.: ………………….. Program/ Programme : ……………………………………. No. Kad Pengenalan/Pasport/ I.C No./Passport No.: …………………………………….. Jantina/Gender : ………………………………...... Taraf Perkahwinan/Marital Status : ……………………… Agama/ Religion: ............. Alamat Tetap/Permanent Address : …………………………………………………………………………………………………….......................................... ………………………………………………………………………………………………………………………………………………………………………………………………….. No. Telefon Rumah/House Phone No. : …………………………………. No. Tel. Bimbit/Handphone No.: .……………................... Warganegara/Citizenship : …………………………………. Bangsa /Race : …………………......... Umur/Age : ……………………………....... Biasiswa/Scholarship: ………………………………………….......................
B. AKTIVITI SEMASA DI UNIVERSITI (WHILST ACTIVITIES AT UNIVERSITY) Sila Lampirkan Buku Rekod Aktiviti Mahasiswa/Please attach the Student Activity Record Book C. SEBAB-SEBAB PERMOHONAN/REASON FOR APPLICATION
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Lekatkan Gambar Bersaiz pasport (Please attach a
passport size photo)
NO. SEMAKAN : 03 NO. ISU : 02 TARIKH KUATKUASA : 30/04/2013 2/2
OPERASI PERKHIDMATAN SOKONGAN
KOLEJ-KOLEJ Kod Dokumen: OPR/KOLEJ/BR02/PEN003
BORANG PERTUKARAN KOLEJ Transfer of College Form
D. AKUAN/ DECLARATION
1. Saya seperti nama dan alamat di atas No. KP/No.Pasport …………………………………………..mengaku bahawa semua
keterangan yang telah saya berikan dalam borang permohonan ini adalah benar. I hereby as name and address mentioned above, I.C No./Passport No. ................................................. confirm the information given in this form is true.
2. Saya sedia mematuhi segala peraturan-peraturan yang dikenakan kepada saya mengikut Akta Universiti dan Kolej Universiti 1971, Perlembagaan Universiti Putra Malaysia (P.U.A 106). I hereby will obey that was set according to the University and College University Act 1971, Constitution of University Putra Malaysia (P.U.A 106).
3. Saya sedia mematuhi apa-apa perintah, suruhan atau arahan secara lisan atau bertulis daripada Pengetua atau mana-mana orang lain yang diberikan kuasa olehnya. I will obey any oral or return instruction from the Principal or any authorized person.
……………………………………………………………. ……………………………. Tandatangan Pelajar/Student signature Tarikh/Date
KELULUSAN KOLEJ SEMASA/ APPROVAL FROM RECENT COLLEGE
Permohonan Lulus/ Tidak Lulus/ Application Approved/Not Approved Ulasan/Comments : …………………………………………………………………
Tarikh/Date : ………………………..
ULASAN KOLEJ YANG DIMOHON/COMMENTS FROM COLLEGE APPLIED
Permohonan Lulus/Tidak Lulus/Application Approved/Not Approved Ulasan Pengetua Kolej (Jika ada) Principal comment (if applicable)
………………………………………………………………………………………….…………………………………………………………………………………………………………
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………………………………………………… ……………………….. Tandatangan Pengetua dan Cap Tarikh/Date Principal Signature and Stamp
UNTUK KEGUNAAN PEJABAT
Kunci bilik telah dipulangkan pada: …………………………………… ………………………………………………………………….. …………………….. Tandatangan Pengetua/Pengurus/Penolong Pengurus/PJSD dan Cap Tarikh
……………………………… Tandatangan Pengetua/PK/PPK & Cap/ Principal/PK/PPK Signature and Stamp