PERMOHONAN UNTUK APPLICATION FOR

PENANGGUHAN LANJUT TEMPOH TARIK DIRI TUKAR STATUS DEFERMENT EXTENSION WITHDRAWAL STATUS CONVERSION

BAHAGIAN A :DILENGKAPKAN OLEH PEMOHONPart A : Completed By ApplicantNama penuhFull Name

Alamat terkiniCurrent Address

No. Matrik Matric No.

No. Tel & Emel Phone No. & Email

Program Pengajian Programme of StudyFakulti/Pusat Faculty/CentreModule Di Pohon (tempoh) Applied Module (duration)

Sesi Akademik: _________________ Academic Session

Tukar Status (jika berkaitan) Change Status (if applicable)

Penuh Masa ke Separuh Masa Separuh Masa ke Penuh Masa Full Time to Part Time Part Time to Full Time

Justifikasi Permohonan Justification of Application

Tandatangan PelajarSignature of Student

Tarikh Date

1

BAHAGIAN C: DILENGKAPKAN OLEH DEKAN / PENGARAHPart C : Completed By DeanPerakuan Dekan / Pengarah Recommendation by Dean / Director

Disokong Supported Tidak Disokong Not Supported

________________________________________________________________________

________________________________________________________________________

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Tandatangan / Cop Rasmi Signature / Official Stamp

TarikhDate

Kegunaan Pejabat / For office use:

Diterima OlehAccepted by

Tindakan SeterusnyaNext Action

TandatanganSignature

Tarikh Date

2