buku tawaran kemasukan dwi bahasa semester 2 sesi 20112012.pdf

VERSI

BAHASA MELAYU

1

UNIVERSITI TUN HUSSEIN ONN MALAYSIA

Senarai Semak Buku Tawaran Kemasukan

Perkara-perkara yang terkandung di dalam buku ini adalah seperti berikut :

Bil. Perkara Rujukan Muka surat

1 Pelan Tunjuk Arah Ke UTHM 5

2 Pelan Lokasi Dan Kolej Kediaman UTHM 7

3 Pelan Kampus Induk UTHM 9

4 Syarat-Syarat Tambahan Tawaran Kemasukan Ke UTHM Lampiran 1 11

5 Kadar Yuran Bagi Pelajar Baru (Bayaran Semasa Pendaftaran)

Lampiran 2A 13

6 Bayaran Bon Cagaran Bagi Pelajar Luar Negara Lampiran 2B 14

7 Arahan Pembayaran Bagi Program Sarjana Muda/Diploma Lampiran 3 15

8 Kemudahan-Kemudahan Yang Boleh Diperolehi Di Dalam Kampus Dan Di Sekitar UTHM

Lampiran 4 16

9 Keperluan Semasa Program Minggu Haluan Siswa Lampiran 5A 17

10 Etika Berpakaian Semasa Hari Pendaftaran Lampiran 5B 18

11 Senarai Semak Pejabat Bendahari Lampiran 6A 19

12 Borang Perakuan Dan Permohonan Bayaran Melalui Bank BEN/UBAP/001 20

13 Senarai Semak Pusat Kesihatan Universiti (PKU) Lampiran 6B 21

14 Borang Akuan Doktor UTHM.PA/PKU1 23 – 28

15 Perakuan Kebenaran Bius Dan Pembedahan UTHM.PA/PKU2 29

16 Senarai Semak Pejabat Kolej Kediaman Lampiran 6C 31

17 Surat Perjanjian Penerimaan Tawaran Menghuni Kolej Kediaman UTHM.PA/PDS1 33

18 Senarai Semak Pejabat Hal Ehwal Pelajar (HEP) Lampiran 6D 35

19 Panduan Mengisi Borang Maklumat Pelajar UTHM.PA/PPA1 37 - 56

20 Kad Jawapan UTHM.PA/KJ

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PELAN KE UNIVERSITI TUN HUSSEIN ONN MALAYSIA (Pelajar yang bercadang menggunakan Lebuhraya Utara - Selatan untuk ke UTHM adalah dinasihatkan melalui

susur keluar Tol Ayer Hitam bagi keselesaan perjalanan)

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UTHM

Lampiran 1

TAWARAN KEMASUKAN KE UNIVERSITI TUN HUSSEIN ONN MALAYSIA (SYARAT-SYARAT TAMBAHAN)

1. Bagi pelajar program Sarjana Muda, sekiranya anda tidak mendapat Tahap 3 (Band 3) dalam peperiksaan Malaysian University English Test (MUET) semasa menerima tawaran ini, anda diwajibkan mengambil peperiksaan tersebut semasa dalam tempoh pengajian dengan mendapat Tahap 3 (Band 3) sebelum penganugerahan.

2. Segala maklumat yang anda kemukakan di dalam borang permohonan dan tawaran kemasukan mestilah

benar. Jika terdapat maklumat palsu, pihak Universiti berhak menarik balik tawaran ini atau menamatkan pengajian anda pada bila-bila masa.

3. Anda mestilah sihat. Ini hendaklah dibuktikan dengan Borang Akuan Doktor (UTHM.PA/PKU1) yang

terdapat di dalam set tawaran kemasukan. Keputusan muktamad pemeriksaan kesihatan ini tertakluk kepada perakuan Pegawai Perubatan Universiti.

4. Anda pada setiap masa adalah tertakluk kepada Akta Universiti dan Kolej Universiti 1971, Kaedah-Kaedah

Universiti Tun Hussein Onn Malaysia (Tatatertib Pelajar) dan peraturan lain yang berkuatkuasa di Universiti Tun Hussein Onn Malaysia.

5. Anda diwajibkan menghadiri kursus Bina Negara anjuran Biro Tata Negara (BTN) atau Himpunan Patriot

Negara (HIMPUN) yang akan ditetapkan oleh pihak Universiti. 6. Semua pelajar diwajibkan tinggal di Kolej Kediaman sepanjang tahun pertama pengajian. Pelajar

yang keluar atau menarik diri dari tinggal di Kolej Kediaman adalah tertakluk kepada peraturan Universiti yang sedang berkuatkuasa.

7. Kadar yuran Kolej Kediaman tertakluk kepada pindaan dari semasa ke semasa. 8. Pelajar yang diluluskan permohonan penangguhan pengajian semasa/cuti sakit oleh pihak berkuasa

Universiti pada sesuatu semester dikehendaki menjelaskan yuran Kolej Kediaman mengikut kiraan sebenar pelajar tersebut tinggal di Kolej Kediaman.

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Lampiran 2A

KADAR YURAN BAGI PELAJAR BARU KEMASUKAN SEMESTER II SESI AKADEMIK 2011/2012

(BAYARAN SEMASA PENDAFTARAN)

PROGRAM SARJANA MUDA (RM)*

BUTIRAN BAYARAN

PELAJAR TEMPATAN

YURAN SEKALI SEPANJANG PENGAJIAN

1. Yuran Pendaftaran 2. Yuran Alumni

3. Yuran Ko-Kurikulum

4. Yuran Minggu Haluan Siswa

YURAN BERULANG (PERSEMESTER)

5. Yuran Perkhidmatan UTHM 6. Yuran Pelajaran

7. Yuran Kolej Kediaman

8. Insuran (setahun)

20.00

100.00

200.00

130.00

180.00

700.00

479.50

-

JUMLAH BAYARAN

1,809.50

* Tertakluk Kepada Pindaan

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Lampiran 3

ARAHAN PEMBAYARAN BAGI PROGRAM SARJANA MUDA/DIPLOMA 1. Semua pelajar dikehendaki menjelaskan keseluruhan bayaran dengan menggunakan slip wang tunai masuk yang

disertakan bersama surat tawaran kemasukan melalui mana-mana cawangan Bank Muamalat Malaysia Berhad (BMMB).

2. Jumlah bayaran yang perlu dijelaskan adalah seperti yang tertera di slip wang tunai masuk BMMB. 3. Sila bawa bersama slip wang tunai masuk (salinan Pejabat Bendahari) yang telah dicetak oleh BMMB dan

serahkan ke kaunter Pejabat Bendahari pada hari pendaftaran. 4. Pelajar baru yang mendapat tajaan dikehendaki menyerahkan satu salinan surat tajaan semasa hari pendaftaran. 5. Maklumat tambahan :

a. Sekiranya kemudahan Bank Muamalat Malaysia Berhad (BMMB) tiada/sukar diperolehi, bayaran boleh dibuat melalui Draf Bank/Kiriman Wang/Wang Pos atas nama “UNIVERSITI TUN HUSSEIN ONN MALAYSIA” dan menyerahkannya di kaunter Pejabat Bendahari pada hari pendaftaran.

b. Semua pelajar baru yang memohon biasiswa/pinjaman dikehendaki membuka akaun BMMB dari mana-

mana cawangan yang berdekatan dengan tempat tinggal. c. Kemudahan membuka akaun bank juga akan disediakan semasa hari pendaftaran dan pelajar yang ingin

membuka akaun bank, diminta menyediakan satu salinan kad pengenalan/MyKad dan bayaran minimum sebanyak RM20.00.

d. Pelajar baru yang diluluskan untuk menarik diri atau berhenti dari Universiti di dalam tempoh 14 hari

daripada tarikh pelajar mendaftar adalah layak mendapatkan semula sebahagian daripada yuran yang telah dijelaskan. Tiada pemulangan sekiranya permohonan menarik diri dibuat selepas tempoh di atas.

e. Pelajar yang menarik diri atau berhenti selepas tempoh 14 hari dari tarikh pelajar mendaftar tetapi belum

menjelaskan sebahagian daripada yuran dikehendaki menjelaskan semua yuran yang belum dibayar. f. Sebarang pertanyaan mengenai masalah pembayaran, sila hubungi Bendahari Universiti Tun Hussein

Onn Malaysia melalui :

No. Telefon : 07-4537085 (Pn. Zuhaila) atau 07-4537080 (Pn. Norhafisah) atau 07-4537066 (Pejabat Am) No. Faks : 07-4536040 E-mail : [email protected] atau [email protected]

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Lampiran 4

KEMUDAHAN-KEMUDAHAN YANG BOLEH DIPEROLEHI

DI DALAM KAMPUS DAN DI SEKITAR UTHM

Kemudahan-kemudahan yang boleh diperolehi di dalam kampus dan di sekitar UTHM adalah seperti disenaraikan di bawah: a) Dalam Kampus Induk

• Kedai Koperasi UTHM Berhad.

• Telefon Telesiswa dan Telefon Awam

• Perkhidmatan Fotokopi dan Penjilidan

• Perkhidmatan Kantin, Kafeteria dan Aked

• Bank Muamalat Malaysia Berhad (BMMB)

• Kiosk Mesin ATM (BMMB, CIMB Bank, Bank Rakyat, BSN, RHB Islamic Bank & Agro Bank)

• Kiosk Perkhidmatan Pelajar .

• Pusat Kesihatan Universiti.

• Makmal Komputer dan Kemudahan Internet

• Pos Mini

• Kemudahan Sukan dan Rekreasi i) Mini Stadium dan Padang Permainan ii) Gelanggang Futsal dan Hoki iii) Dewan Badminton dan Skuash iv) Gimnasium v) Lapang Sasar Golf vi) Trek Jogging vii) Wall Climbing dan lain-lain

b) Luar Kampus

• CIMB Bank

• Public Bank

• Maybank

• Bank Simpanan Nasional (BSN)

• Pejabat Pos

• Klinik Kerajaan dan Swasta

• Hotel D’ Impian Inn (07-4532744)

• Pasaraya

• Balai Polis

• Restoran KFC

• Restoran Mc Donalds

• 7-Eleven dan lain-lain (Kemudahan ini terdapat di sekitar 2 km dari UTHM)

c) Nama-nama hotel di Bandar Batu Pahat (kemudahan kepada keluarga yang memerlukan penginapan)

• Hotel Katerina (07-4337111)

• Hotel Crystal Inn (07-4315222)

• Hotel Landmarks (07-4320001)

• Hotel Silver Inn (07-4315122)

• Hotel Novo Park (07-4328787)

• Hotel Pelican (07-4328111)

• Hotel Garden (07-4315999)

• Hotel Pinetree (07-4319933)

• Rest House Batu Pahat (07-4316122) 16

Lampiran 5A

KEPERLUAN SEMASA PROGRAM MINGGU HALUAN SISWA

SISWA 1. Kemeja putih lengan panjang.

2. Seluar panjang berwarna hitam/biru gelap (bukan jeans).

3. Kasut berwarna gelap.

4. Tali leher

5. Pakaian dan kasut sukan. SISWI 1. Baju kurung berwarna putih.

2. Kain berwarna hitam/biru gelap.

3. Kasut berwarna gelap dan bertutup.

4. Telekung (pelajar beragama Islam sahaja).

5. Pakaian dan kasut sukan.

6. Tudung berwarna putih Nota : i. Kolej Kediaman menyediakan kelengkapan tempat tidur KECUALI cadar,

sarung bantal dan selimut. ii. Kedai Koperasi UTHM ada menjual peralatan harian seperti sabun,

berus gigi, baldi, selipar dan keperluan-keperluan lain. iii. Sila bawa kelengkapan lain secukupnya.

17 Lampiran 5B

ETIKA BERPAKAIAN SEMASA HARI PENDAFTARAN Pelajar Lelaki

• Berpakaian sopan, kemas dan bersih.

• Memakai baju kemeja / Kemeja T berkolar dan baju hendaklah dimasukkan ke dalam seluar.

• Memakai seluar slack.

• Digalakkan memakai tali leher.

• Memakai Kasut.

Pelajar Perempuan

• Berpakaian sopan, kemas dan bersih.

• Digalakkan berbaju kurung / menutup aurat.

• Dibenarkan memakai seluar panjang.

• Memakai kain atau skirt yang labuhnya hendaklah di bawah paras lutut.

• Memakai kasut.

SAHSIAH RUPADIRI Pelajar Lelaki

• Berambut pendek, kemas, tidak terlalu tebal, tidak melepasi mata dan tidak bewarna.

• Dilarang bertindik, memakai rantai, bertatoo, memakai gelang tangan, subang, anting-anting dan apa-apa sahaja perhiasan diri.

• Jambang dan janggut hendaklah dijaga dengan kemas dan rapi.

Pelajar Perempuan

• Rambut hendaklah disisir rapi

• Pemakaian alat solek, barang kemas, perhiasan diri dan pewangi secara sederhana. 18

Lampiran 6A

SENARAI SEMAK PEJABAT BENDAHARI

TINDAKAN (Sila tandakan √ sekiranya dokumen berkenaan telah

dikepilkan)

BIL.

DOKUMEN

PELAJAR

PEJ. BENDAHARI

CATATAN

1. Slip Wang Tunai Masuk Bank Muamalat Malaysia Berhad (BMMB)

2.

Surat Asal Tajaan Dan Salinan (jika ada).

3.

Borang Perakuan Dan Permohonan Bayaran Melalui Bank.

PENTING : 1. Surat Tawaran Kemasukan dan dokumen asal hendaklah dibawa bersama untuk semakan.

2. Sila kepilkan senarai semak ini bersama dengan dokumen, mengikut turutan senarai semak di atas.

3. Sila serahkan dokumen berkenaan di kaunter Pejabat Bendahari semasa hari pendaftaran.

TANDATANGAN : …………………………………………. NAMA : …………………………………………. JANTINA : …………………………………………. PROGRAM : …………………………………………. NO. MATRIK : …………………………………………. TARIKH : ………………………………………….

NO. TELEFON : …………………………………………. (untuk dihubungi)

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BEN/UBAP/001

PEJABAT BENDAHARI UNIVERSITI TUN HUSSEIN ONN MALAYSIA

BORANG PERAKUAN DAN PERMOHONAN BAYARAN MELALUI BANK

Bendahari Universiti Tun Hussein Onn Malaysia Tuan,

Merujuk kepada perkara di atas, saya memohon supaya semua pembayaran Biasiswa / Pinjaman / Pendahuluan / Pemulangan / Elaun yang akan dibuat kepada saya dikreditkan dalam akaun BMMB seperti di bawah :

No. Akaun Bank Pelajar :

2. Salinan muka pertama buku akaun simpanan adalah disertakan. 3. Saya mengaku akan memberitahu Pejabat Bendahari dengan serta merta sekiranya terdapat apa-apa perubahan yang

berkaitan, untuk mengelakkan sebarang masalah kelewatan pembayaran.

4. Saya juga memberi kuasa kepada Bendahari UTHM untuk meminta Pengurus BMMB menahan atau mendebitkan akaun saya sekiranya terdapat kesilapan pembayaran yang telah dibuat. Jika pembayaran berkenaan telah dikeluarkan dari bank, saya bersetuju dan mengaku untuk membayar balik kepada Bendahari UTHM dalam masa 14 hari dari tarikh tuntutan diterima atau sekiranya kesilapan tersebut disedari oleh saya terlebih dahulu.

5. Saya juga mengaku akan mengembalikan mana-mana pembayaran biasiswa / pinjaman / pendahuluan / pemulangan / elaun jika saya tidak layak mendapatnya atau menolak tawaran penganjur.

6. Kegagalan memulangkan bayaran seperti dikehendaki di para 4 dan 5 ( jika berkenaan ) membolehkan pihak Universiti mengambil tindakan ke atas saya atau penjamin atau kedua-duanya sekali mengikut apa yang telah ditetapkan oleh pihak Universiti.

Saya memahami perakuan di atas dan bertanggungjawab terhadapnya.

Sekian , terima kasih.

Yang benar, …………………………………… (Tandatangan) Nama : ……………………………………………………… No. Kad Pengenalan/MyKad - -

(Sila gunakan no. kad pengenalan yang sama di dalam buku tawaran kemasukan) Program :……………………………………. No Matrik :……………………………………. Nama Penganjur :………………………….. Tarikh :…………………………………….. (jika ada) Borang ini perlu diisi dengan lengkap serta jelas dan hendaklah diserahkan di kaunter Pejabat Bendahari UTHM semasa hari pendaftaran.

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Lampiran 6B

SENARAI SEMAK PUSAT KESIHATAN UNIVERSITI (PKU)


dikepilkan)

BIL.

DOKUMEN

PELAJAR

PKU

CATATAN

1.

Borang Akuan Doktor (UTHM.PA/PKU1)

2.

Perakuan Kebenaran Bius Dan Pembedahan (UTHM.PA/PKU2)

3.

Filem X-Ray berserta Laporan


2. Sila kepilkan senarai semak ini bersama dengan dokumen, mengikut turutan senarai semak di atas.

3. Sila serahkan dokumen berkenaan di kaunter Pusat Kesihatan Universiti semasa hari pendaftaran. TANDATANGAN : ………………………………………….. NAMA : ………………………………………….. JANTINA : ………………………………………….. PROGRAM : ………………………………………….. NO. MATRIK : ………………………………………….. TARIKH : ………………………………………….. NO. TELEFON : ………………………………………….. (untuk dihubungi)

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UTHM.PA/PKU1

BORANG AKUAN DOKTOR (Sila serahkan di kaunter Pusat Kesihatan Universiti semasa pendaftaran)

NO. MATRIK PELAJAR KOD PROGRAM

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PEMERIKSAAN DOKTOR UNTUK MENGIKUTI PROGRAM PENGAJIAN DI UNIVERSITI TUN HUSSEIN ONN MALAYSIA

i. Anda hendaklah menjawab SEMUA SOALAN di BAHAGIAN I sebelum menyerahkan borang ini kepada doktor

yang memeriksa anda. ii. Jika didapati keterangan anda palsu atau anda sengaja tidak memberikan keterangan, pihak Universiti berhak

menarik balik penawaran daripada mengikuti program pengajian di Universiti ini. iii. Untuk BAHAGIAN II, anda boleh membuat pemeriksaan dengan mana-mana doktor kerajaan atau swasta yang

dapat menjalankan semua pemeriksaan dan ujian yang diperlukan. iv. Universiti tidak akan menanggung sebarang bayaran yang dikenakan untuk pemeriksaan dan ujian ini.

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BAHAGIAN I : (Untuk dipenuhi oleh pelajar) 1. Nama Pelajar (HURUF BESAR) ……………………………………………………………………………. 2. Nama Bapa / Ibu / Penjaga (HURUF BESAR) …………………………………………………………….. 3. Alamat Tetap ………………………………………………………………………………………………...

………………………………………………………………………………………………………………. ……………………………………………………………………………………………………………….

4. Jantina : Lelaki Perempuan

5. Status : Bujang Berkahwin :

Jika Telah Berkahwin : Mengandung : Ya Tidak

6. No. Kad Pengenalan/MyKad

Lama : Baru :

7. Tarikh Lahir :

H H B B T T

8. Adakah anda mengidap ?

a. Batuk Kering (Tuberculosis) YA / TIDAK* b. Lelah (Asthma) YA / TIDAK* c. Penyakit Jantung YA / TIDAK* d. Sakit Jiwa YA / TIDAK* e. Gila Babi (Epilepsy) YA / TIDAK* f. Kusta (Leprosy) YA / TIDAK* g. Kecacatan anggota YA / TIDAK* h. Penyakit lain yang memerlukan bantuan / rawatan berterusan YA / TIDAK*

Jika ‘YA’ nyatakan dengan lengkap ...........................................................................................

9. Adakah ahli keluarga atau saudara mara anda mengidap penyakit berikut ?

a. Batuk Kering (Tuberculosis) YA / TIDAK* b. Lelah (Asthma) YA / TIDAK* c. Sakit Jiwa YA / TIDAK* d. Gila Babi (Epilepsy) YA / TIDAK* e. Kusta (Leprosy) YA / TIDAK*

Jika ‘YA’ nyatakan dengan lengkap ...........................................................................................

PENGAKUAN

Saya dengan ini mengaku bahawa keterangan yang diberikan di atas adalah lengkap dan benar. Tarikh : ........................................... Tandatangan : ....................................... * Potong yang tidak berkenaan.

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BAHAGIAN II : (Untuk dipenuhi oleh doktor yang memeriksa) Peringatan : i. Jika anda berkaca mata, bawa ia bersama semasa pemeriksaan doktor.

ii. Semua pemeriksaan dan ujian yang tercatat di bahagian ini adalah diwajibkan. Doktor yang memeriksa boleh menjalankan pemeriksaan atau ujian tambahan jika perlu.

1. Umum : a. Pernahkah anda merawat calon ini ? PERNAH/TIDAK PERNAH* b. Jika ‘PERNAH’ apakah penyakit dan rawatannya ?

.................................................................................….....................................................

c. Tinggi ........................................ cm. d. Berat ........................................ kg. e. Sejarah allergi ...................................................................…......................................... 2. Mata :

a. Penglihatan tanpa cermin mata Kanan ..............................

Kiri ..............................

b. Penglihatan dengan cermin mata Kanan ..............................

Kiri ..............................

c. Penglihatan warna (Colour Vision) (SEKURANG- KURANGNYA MENGGUNAKAN ISHIHARA CHART) NORMAL / TIDAK NORMAL*

d. Fundoskopi NORMAL / TIDAK NORMAL*

Jika ‘TIDAK NORMAL’ ..........................................................................................................

3. Telinga, Hidung dan Tekak :

a. Pendengaran NORMAL / TIDAK NORMAL*

b. Gegendang telinga (Tympanic Membrane) NORMAL / TIDAK NORMAL*

c. Hidung NORMAL / TIDAK NORMAL*

d. Mulut NORMAL / TIDAK NORMAL*

e. Tekak NORMAL / TIDAK NORMAL*

f. Tonsil NORMAL / TIDAK NORMAL*

Jika ‘TIDAK NORMAL’ .............................................…...........................................................

4. Gigi : NORMAL / TIDAK NORMAL*

Jika ‘TIDAK NORMAL’ ............................................................................…...........................

.................................................................................................................….......................................

* Potong yang tidak berkenaan

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5. Dada dan Paru-paru :

a. Buah dada NORMAL / TIDAK NORMAL*

b. Paru-paru NORMAL / TIDAK NORMAL*

c. X-Ray dada ** NORMAL / TIDAK NORMAL*


........................................................................................................................................................... 6. Kardiovaskular :

a. Tekanan darah (Blood Pressure) ................................ mm Hg.

b. Nadi (Pulse) ................................/ min

c. Bunyi jantung (Heart Sound) NORMAL / TIDAK NORMAL*

d. Saiz jantung (Heart Size) NORMAL / TIDAK NORMAL*


...........................................................................................................................................................

7. Abdomen :

a. Hati (Liver) NORMAL / TIDAK NORMAL*

b. Limpa (Spleen) NORMAL / TIDAK NORMAL*

c. Saiz buah pinggang (Kidney) NORMAL / TIDAK NORMAL*

d. Lain-lain NORMAL / TIDAK NORMAL*

Jika ‘TIDAK NORMAL’ ………………………………………………………………

…………………………………………………………………………………………...

8. Genitalia : NORMAL / TIDAK NORMAL*

Jika ‘TIDAK NORMAL’ ……………………………………………………………...

………………………………………………………………………………………….. 9. Maskularskeletal :

a. Tulang belakang (Spine) NORMAL / TIDAK NORMAL*

b. Anggota tangan (Upper limb) NORMAL / TIDAK NORMAL*

c. Anggota kaki (Lower limb) NORMAL / TIDAK NORMAL*

d. ‘Reflexes’ NORMAL / TIDAK NORMAL*

e. Sensori NORMAL / TIDAK NORMAL*

Jika ‘TIDAK NORMAL’ …………………………………………………………….

……………………………………………………………………………………….....

* Potong yang tidak berkenaan ** Filem X-Ray dada perlu dilampirkan.

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10. Pemeriksaan air kencing

a. ‘S. Gravity’ NORMAL / TIDAK NORMAL* b. Albumin TIADA / ADA* c. Glukos TIADA / ADA * d. Mikroskopik NORMAL / TIDAK NORMAL* Jika ‘ADA’ atau ‘TIDAK NORMAL’ ......................................................................................

............................................................................................................................................................ 11. Ujian pengesanan DADAH di dalam air kencing : NEGATIF / POSITIF

(Morphine & Cannabinoid) 12. Pemeriksaan Lain .............................................................................................................................................................

.............................................................................................................................................................

* Potong yang tidak berkenaan.

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PERAKUAN DOKTOR YANG MEMERIKSA

Saya mengaku bahawa saya telah memeriksa Encik / Puan / Cik ………………………………………………. dan mengesahkan BAHAGIAN I adalah benar. Saya dapati beliau :

BIL MASALAH ADA TIADA

1.

Mengidap penyakit berjangkit

2.

Mengidap penyakit jiwa

3.

Mempunyai kecacatan fizikal

4.

Mempunyai masalah kesihatan lain dari 1, 2 dan 3

Dan saya berpendapat beliau :

BIL TINDAKAN PERLU TIDAK PERLU

1.

Rawatan lanjutan

2.

Dirujuk kepada Pakar

Jika “ADA” atau “PERLU” ……………………………………………………………………………………

…………………………………………………………………………………………………………………...

…………………………………………………………………………………………………………………...

……………………………………………………………………………………………………………………

Tarikh : ..................................... Tandatangan : ……………………………….

Nama : ……………………………….

Jawatan : ……………………………….

Hospital / Klinik : ………………………………. (Cop Rasmi)

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UTHM.PA/PKU2

PERAKUAN KEBENARAN BIUS DAN PEMBEDAHAN (Untuk calon di bawah 21 tahun)

(Sila serahkan di kaunter Pusat Kesihatan Universiti semasa pendaftaran) Pegawai Perubatan, Universiti Tun Hussein Onn Malaysia Saya…………………………………………………………………………………………………………………………….

No. Kad Pengenalan/MyKad/No.Passport…………………………………….. Bapa/Ibu/Penjaga kepada (Nama Pelajar)

………………………………………………………... dengan ini memberi kuasa kepada tuan untuk menandatangani

kebenaran bagi pihak saya, jika pada pandangan doktor yang anak/anak jagaan saya ini memerlukan rawatan bius / pembedahan

pada masa yang diperlukan.

Yang benar, ……………………………………………. (Tandatangan Bapa/Ibu/Penjaga) Tarikh : …………………………………... Nama Bapa / Ibu / Penjaga

…………………………………………….

Alamat: ……………………………………

…………………………………………….

…………………………………………….

Nombor Telefon : ………………………...

29

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Lampiran 6C

SENARAI SEMAK PEJABAT KOLEJ KEDIAMAN


dikepilkan)

BIL.

DOKUMEN

PELAJAR

KOLEJ

KEDIAMAN

CATATAN

1. Surat Perjanjian Penerimaan Tawaran Menghuni Kolej Kediaman bagi Sesi Akademik _____________ (UTHM.PA/PDS1)

2. Dua (2) keping gambar berukuran pasport (berwarna) dengan mencatatkan nama dan nombor kad pengenalan/no. passport di belakang gambar.

PENTING : 1. Surat Tawaran Kemasukan dan dokumen asal hendaklah dibawa bersama untuk semakan

2. Sila kepilkan senarai semakan ini bersama dengan dokumen, mengikut turutan senarai semak di atas.

3. Sila serahkan dokumen berkenaan di kaunter Pejabat Kolej Kediaman semasa pendaftaran.

TANDATANGAN : ………………………………………….. NAMA : ………………………………………….. JANTINA : ………………………………………….. FAKULTI : ………………………………………….. NO. MATRIK : ………………………………………….. TARIKH : ………………………………………….. NO. TELEFON : ………………………………………….. (untuk dihubungi)

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UTHM.PA/PDS1

SURAT PERJANJIAN PENERIMAAN TAWARAN MENGHUNI KOLEJ KEDIAMAN

BAGI SESI AKADEMIK ___________________ Bahawasanya saya …………………………………………………………………………………………………………...

No. Kad Pengenalan/MyKad/no. passport………………………….. dengan ini bersetuju untuk menerima tawaran Universiti

Tun Hussein Onn Malaysia (UTHM) untuk menghuni di Kolej Kediaman, UTHM bagi tempoh SATU (1) tahun sesi pengajian

saya berkuatkuasa mulai tarikh seperti di bawah dan saya berjanji akan mematuhi syarat-syarat seperti berikut :

1. Mematuhi peraturan-peraturan sebagaimana tertakluk di bawah Akta Universiti dan Kolej Universiti 1971,

Kaedah-Kaedah Universiti Tun Hussein Onn Malaysia (Tatatertib Pelajar-Pelajar) dan segala peraturan Universiti

Tun Hussein Onn Malaysia (UTHM) serta peraturan-peraturan Kolej Kediaman yang berkuatkuasa dan segala

peraturan serta arahan yang akan dikeluarkan dari semasa ke semasa.

2. Memberi kerjasama dan komitmen di dalam semua aktiviti Kolej Kediaman.

3. Bersetuju untuk menjelaskan segala pembayaran yuran Kolej Kediaman dan apa-apa bayaran yang perlu dibayar

oleh saya sepanjang tempoh kontrak saya.

4. Bersetuju bahawa yuran Kolej Kediaman saya tidak akan dikembalikan sekiranya saya keluar daripada Kolej

Kediaman di dalam tempoh tersebut atau saya diarahkan keluar dari Kolej Kediaman atas sebab tindakan

tatatertib.

5. Bersetuju untuk menanggung apa-apa tuntutan gantirugi atau apa-apa penalti yang dikenakan ke atas saya

sekiranya saya melanggar mana-mana peraturan Kolej Kediaman.

6. Bersetuju untuk melepaskan tanggungan terhadap pihak Kolej Kediaman atas apa jua tuntutan yang berpunca

daripada kecuaian diri saya sendiri.

Yang benar, Saksi :

Tandatangan pelajar : ……………………… Tandatangan : ………………………..

Nama Bapa/ Ibu/ Penjaga

…………………………………………….

Tarikh : ……………………….. Tarikh : …………………………………

No. telefon (Rumah) : …………………….

No. telefon (H/P) : ………………………..

33

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Lampiran 6D

SENARAI SEMAK PEJABAT HAL EHWAL PELAJAR (HEP)

TINDAKAN

(Sila tandakan √ sekiranya butiran berkenaan telah diterima semasa pendaftaran)

BIL.

BUTIRAN

PELAJAR

HEP

CATATAN

1.

Baju Batik

2.

T-Shirt Berkolar Lengan Panjang

3.

Beg

4.

Buku Panduan Pelajar


2. Sila serahkan senarai semak ini di kaunter Pejabat Hal Ehwal Pelajar semasa pendaftaran. TANDATANGAN : ………………………………………….. NAMA : ………………………………………….. JANTINA : ………………………………………….. PROGRAM : ………………………………………….. NO. MATRIK : …………………………………………. TARIKH : ………………………………………….. NO. TELEFON : ………………………………………….. (untuk dihubungi)

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PANDUAN MENGISI BORANG MAKLUMAT PELAJAR

Borang UTHM. PA/PPA1 (Borang disediakan di dalam Fail Mahasiswa)

__________________________________________________________________________________________

1. Maklumat yang dinyatakan di dalam Borang (UTHM.PA/PPA1) ini adalah amat penting dan akan dikemaskini ke dalam Sistem Maklumat Pelajar UTHM.

2. Sila isi Borang Maklumat Pelajar (UTHM.PA/PPA1) dengan menggunakan

ballpen berdakwat hitam/biru. 3. Sila gunakan HURUF BESAR semasa mengisikan maklumat sama ada di

petak kosong atau di garisan yang disediakan. 4. Sila pastikan setiap maklumat telah diberi dengan lengkap dan betul sebelum

mengesahkan kesahihan maklumat anda di ruang pengakuan.

37

1. NAMA

Nama anda mestilah sama sepertimana tertera dalam kad pengenalan/MyKad. Isikan nama anda dengan HURUF BESAR di dalam petak-petak yang disediakan. Gunakan satu petak bagi setiap huruf dan kosongkan satu petak di antara dua perkataan.

Contoh : Jika nama anda ialah MOHD. HASRIZAL BIN MOHD. HARITH

NAMA :

M O H D . H A S R I Z A L B I N M O H D . H A R I T H

Jika petak-petak yang disediakan tidak mencukupi, gunakan singkatan supaya petak mencukupi tetapi singkatan yang digunakan mestilah mudah difahami.

Contoh : Jika nama anda ialah TENGKU INTAN BINTI TENGKU MOHD. KASIM

NAMA :

T G . I N T A N B T . T G . M O H D K A S I M 2. NAMA LAIN

Sila nyatakan nama lain atau gelaran anda selain daripada nama sebenar. (Jika ada)

Contoh : Jika nama anda LIM KAR CHAI dan nama atau gelaran lain ialah JASON LIM

NAMA LAIN :

J A S O N L I M

3. NOMBOR KAD PENGENALAN/MYKAD/LAIN-LAIN PENGENALAN DIRI

Nombor kad pengenalan/MyKad/lain-lain pengenalan diri mestilah ditulis dengan tepat seperti berikut :- Contoh :

NO. KAD PENGENALAN/MYKAD/LAIN-LAIN PENGENALAN DIRI

Jika anggota Tentera/Polis : T123456/RF1234 Jika 12 angka (MyKad) : 880503-02-5555 Lain-lain (i.e. Pasport) : 0062117

4. NOMBOR MATRIK

Nombor Matrik dikeluarkan oleh pihak Universiti. Sila tuliskan nombor matrik anda dengan merujuk kepada nombor matrik yang dinyatakan pada surat tawaran kemasukan. Nombor ini adalah nombor pengenalan anda di Universiti. Anda dikehendaki menyimpan dan mengingati dengan baik nombor matrik anda.

Contoh : Jika nombor matrik anda AF110001 NOMBOR MATRIK :

39

T 1 2 3 4 5 6

8 8 0 5 0 3 - 0 2 - 5 5 5 5 0 0 0 6 2 1 1 7

A F 1 1 0 0 0 1

BAHAGIAN A1 : MAKLUMAT DAN ALAMAT PELAJAR

5. FAKULTI

FAKULTI KOD Fakulti Kejuruteraan Awam dan Alam Sekitar 01 Fakulti Kejuruteraan Elektrik dan Elektronik 02 Fakulti Kejuruteraan Mekanikal dan Pembuatan 03 Fakulti Pengurusan Teknologi, Perniagaan dan Keusahawanan 04 Fakulti Pendidikan Teknikal 05 Fakulti Sains Komputer dan Teknologi Maklumat 06 Fakulti Sains, Teknologi dan Pembangunan Insan 07 Pusat Pengajian Diploma 08

Contoh : Jika fakulti anda ialah Fakulti Kejuruteraan Awam dan Alam Sekitar (sila rujuk surat tawaran kemasukan)

FAKULTI :

6. KOD PROGRAM

PROGRAM

KOD

SARJANA MUDA Fakulti Kejuruteraan Awam dan Alam Sekitar (FKAAS) Sarjana Muda Kejuruteraan Awam Dengan Kepujian Fakulti Kejuruteraan Elektrik dan Elektronik (FKEE) Sarjana Muda Kejuruteraan Elektrik (Sistem Kuasa) Dengan Kepujian Sarjana Muda Kejuruteraan Elektronik (Komunikasi) Dengan Kepujian Sarjana Muda Kejuruteraan Elektronik (Kejuruteraan Komputer) Dengan Kepujian Sarjana Muda Kejuruteraan Elektronik (Mekatronik) Dengan Kepujian Sarjana Muda Kejuruteraan Elektronik (Mikroelektronik) Dengan Kepujian Sarjana Muda Kejuruteraan Elektronik (Elektronik Perubatan) Dengan Kepujian Fakulti Kejuruteraan Mekanikal dan Pembuatan (FKMP) Sarjana Muda Kejuruteraan Mekanikal Dengan Kepujian Sarjana Muda Teknologi Kejuruteraan Aeronautik (Penerbangan Profesional) Dengan Kepujian Sarjana Muda Teknologi Kejuruteraan Aeronautik (Penyenggaraan Pesawat Terbang) Dengan Kepujian Fakulti Pengurusan Teknologi, Perniagaan dan Keusahawanan (FPTPK) Sarjana Muda Pengurusan Teknologi Dengan Kepujian Sarjana Muda Pengurusan Teknologi (Pengeluaran dan Operasi) Dengan Kepujian Sarjana Muda Pengurusan Teknologi (Pembinaan) Dengan Kepujian Sarjana Muda Pengurusan Harta Tanah Dengan Kepujian Fakulti Pendidikan Teknikal (FPTek) Sarjana Muda Pendidikan Vokasional (Elektrik Dan Elektronik) Dengan Kepujian Sarjana Muda Pendidikan (Sekolah Rendah) Dengan Kepujian Sarjana Muda Pendidikan Teknik Dan Vokasional Fakulti Sains Komputer dan Teknologi Maklumat (FSKTM) Sarjana Muda Teknologi Maklumat Fakulti Sains, Teknologi dan Pembangunan Insan (FSTPI) Sarjana Muda Sains (Matematik Teknologi) Dengan Kepujian Sarjana Muda Sains (Statistik Industri) Dengan Kepujian Sarjana Muda Sains (Fizik Gunaan) Dengan Kepujian Sarjana Muda Sains (Teknologi Makanan) Dengan Kepujian

BFF

BEF BEB BEC BEH BED BEU

BDD BDC BDM

BPA BPB BPC BPD

BBE BBR BBV

BIT

BWA BWB BWC BWD

0 1

40

Contoh 1: Jika anda mengikuti program Sarjana Muda Kejuruteraan Awam Dengan Kepujian, masukkan kod BFF

KOD PROGRAM :

Contoh 2 : Jika anda mengikuti program Diploma Kejuruteraan Elektrik Serta Teknologi, masukkan kod DAL.

KOD PROGRAM : 7. TARIKH LAHIR

Contoh : Jika anda dilahirkan pada 13 Mei 1988.

TARIKH LAHIR : H H B B TAHUN

8. JANTINA

JANTINA KOD

Lelaki L Perempuan P

Contoh : Jika anda seorang perempuan.

JANTINA :

41

PROGRAM

KOD

DIPLOMA Pusat Pengajian Diploma Diploma Kejuruteraan Awam Diploma Kejuruteraan Awam Serta Teknologi Diploma Kejuruteraan Elektrik Diploma Kejuruteraan Elektrik Serta Teknologi Diploma Kejuruteraan Mekanikal Diploma Kejuruteraan Mekanikal Serta Teknologi Diploma Teknologi Maklumat

DAA DAC DAE DAL DAM DAI DAT

B F F

D A L

1 3 0 5 1 9 8 8

P

9. KETURUNAN

KETURUNAN KOD KETURUNAN KOD KETURUNAN KOD

Melayu 0100 Tambanuo 0925 Lemanak 1118

Cina 0200 Tagal 0926 Lahanan 1119

India 0300 Tinagas 0927 Lusum/Lugum 1120

India Muslim 0307 Cocos 0928 Matu 1121

Indonesia 0700 Kimaragang 0929 Maloh 1122

Bumiputera Sabah 0800 Bolongan 0930 Melikin 1123

Bajau 0801 Buton 0931 Melaing 1124

Dusun 0802 Bumiputra Sarawak 1000 Murik 1125

Kadazan 0803 Melayu Sarawak 1001 Menondo 1126

Murut 0804 Melanau 1002 Nyamok 1127

Sino-Native 0805 Kedayan 1003 Sebob 1128

Suluk 0806 Iban/Sea Dayak 1004 Seduan 1129

Binadan 0901 Bidayuh/Land Dayak 1005 Sekapan 1130 Bisaya 0902 Kayan 1006 Segalang 1131 Bongol 0903 Kenyah 1007 Sian 1132 Brunei 0904 Murut/Lun Bawang 1008 Sipeng 1133

Dumpas 0905 Kelabit 1009 Saribas 1134

Irranun 0906 Penan/Punan 1010 Sebuyau 1135

Idahan 0907 Bisaya 1101 Skrang 1136

Kwijau 0908 Berawan 1102 Sabah 1137

Kedayan 0909 Belot 1103 Selakan 1138

Lingkabau 0910 Bukit 1104 Selakau 1139

Lundayeh 0911 Balau 1105 Tagal 1140

Lasau 0912 Batang Ai 1106 Tabun 1141

Melanau 0913 Batu Elah 1107 Tutong 1142

Mangkaak 0914 Bukitan 1108 Tanjong 1143

Matagang 0915 Bintulu 1109 Tatau 1144

Minokok 0916 Badang 1110 Taup 1145 Momogun 0918 Dusun 1111 Ukit 1146 Paitan 0919 Jagoi 1112 Umkop 1147 Ramanau 0920 Kiput 1113 Ulu Ai 1148 Rungus 0921 Kajang 1114 Orang Asli 1200 Sungai 0922 Kajaman 1115 (Semenanjung)

Sonsongan 0923 Kanowit 1116 Arab 1301 Sinulahan 0924 Lirong 1117 Khmer (Kemboja) 1308 Lain-lain 1400

Contoh : Jika keturunan anda Melayu.

KETURUNAN : 10. AGAMA

AGAMA KOD

Islam I

Kristian K

Buddha B

Hindu H

Lain-lain L

Contoh : Jika anda beragama Islam

AGAMA :

42

0 1 0 0

I

11. NEGERI LAHIR

NEGERI KOD NEGERI KOD NEGERI KOD

Perak A Pulau Pinang U Sarawak Y Selangor B Perlis R Luar Negara L Pahang C Terengganu T Lain-lain Z Kelantan D Sabah E

Wilayah Persekutuan (Kuala Lumpur)

W

Johor J

Kedah K

Wilayah Persekutuan (Labuan)

V

Melaka M

Negeri Sembilan N

Wilayah Persekutuan (Putrajaya)

P

Contoh : Jika anda dilahirkan di Negeri Selangor.

NEGERI LAHIR :

12. NEGERI KEDIAMAN

Nyatakan negeri di mana anda tinggal sekarang dengan menggunakan kod Negeri Lahir.

Contoh : Jika tempat tinggal anda sekarang di Negeri Johor.

NEGERI KEDIAMAN : 13. KEWARGANEGARAAN

WARGANEGARA KOD

Malaysia M

Filipina F

Indonesia I

Singapura S

Thailand T

Brunei Darussalam U

Penduduk Sementara P

Penduduk Tetap E

Lain-lain L

Contoh : Jika anda seorang warganegara Malaysia.

KEWARGANEGARAAN : 14. TINGGI

Contoh : Jika tinggi anda lebih dari 144 sm (4 kaki 9 inci dan ke atas)

TINGGI :

43

B

J

M

TINGGI KOD

144 sentimeter dan ke atas (4 kaki 9 inci dan ke atas) 1

144 sentimeter dan ke bawah (4 kaki 9 inci dan ke bawah ) 2

1

15. ORANG KURANG UPAYA (OKU)

Adakah anda Orang Kurang Upaya (OKU)?

OKU KOD

Ya 1

Tidak 2

Contoh : Jika anda Orang Kurang Upaya (OKU)

ORANG KURANG UPAYA : 16. RABUN WARNA

RABUN WARNA KOD

Ya 1

Tidak 2

Contoh : Jika anda rabun warna.

RABUN WARNA : 17. TARAF PERKAHWINAN

Contoh : Jika anda bujang.

TARAF PERKAHWINAN : 18. TARIKH PERKAHWINAN

Contoh : Jika anda berkahwin pada 4 Januari 1999.

TARIKH PERKAHWINAN : H H B B TAHUN

19. KAWASAN DUN PELAJAR Sila nyatakan kawasan DUN pelajar 20. KAWASAN PARLIMEN PELAJAR Sila nyatakan kawasan Parlimen pelajar

21. BIASISWA / PINJAMAN NILAI BIASISWA / PINJAMAN

Sila nyatakan Biasiswa / Pinjaman dan nilai yang ditawarkan kepada anda. (jika berkaitan)

44

1

1

TARAF PERKAHWINAN KOD

Bujang 1

Berkahwin 2

Duda/Balu 3

1

0 4 0 1 1 9 9 9

22. ALAMAT TETAP

Alamat tetap ialah alamat kediaman tetap anda. Contoh : Jika alamat anda terlalu panjang, ringkaskan perkataan supaya petak yang disediakan

mencukupi. Ringkasan tersebut mestilah mudah difahami. NO. 6, BLOK 5, JALAN 9/106F, FLAT SRI JOHOR, BATU 3 1/2, JALAN CHERAS, 50400 KUALA LUMPUR. NO. TELEFON : 03-12345678 NO. TELEFON BIMBIT : 012-1234567

POSKOD NO. TELEFON

NO TELEFON BIMBIT

23. ALAMAT SEMASA PENGAJIAN (ALAMAT KOLEJ KEDIAMAN)

Contoh : Jika alamat anda terlalu panjang, ringkaskan perkataan supaya petak yang disediakan mencukupi. Ringkasan tersebut mestilah mudah difahami.

G5D-101, KOLEJ KEDIAMAN TUN FATIMAH, UNIVERSITI TUN HUSSEIN ONN MALAYSIA, 86400 PARIT RAJA, BATU PAHAT, JOHOR.

NO. TELEFON : 07-4540001 NO. TELEFON BIMBIT : 012-1234567

POSKOD NO. TELEFON

NO. TELEFON BIMBIT PERHATIAN :

Sekiranya anda bertukar alamat tetap atau alamat pos, anda boleh mengemaskini alamat tersebut di Sistem Maklumat Pelajar (SMP) dengan mengisi borang pertukaran alamat yang terdapat di Pejabat Pengurusan Akademik. Bagi alamat semasa pengajian anda boleh mengemaskini di SMAP online sendiri. Kegagalan anda mengemaskini alamat akan menyebabkan sebarang urusan surat menyurat kepada anda akan terganggu terutama surat yang membabitkan penganugerahan.

45

N O . 6 , B L O K 5 , J A L A N 9 / 1 0 6 F , F L A T S R I J O H O R , B T . 3 1 / 2 , J A L A N C H E R A S , K U A L A L U M P U R .

5 0 4 0 0 0 3 - 1 2 3 4 5 6 7 8

0 1 2 - 1 2 3 4 5 6 7

G 5 D - 1 0 1 , K O L E J K E D I A M A N T U N F A T I M A H , U N I V T U N H U S S E I N O N N M A L A Y S I A , P A R I T R A J A , B A T U P A H A T , J O H O R .

8 6 4 0 0 0 7 - 4 5 4 0 0 0 1

0 1 2 - 1 2 3 4 5 6 7

1. PERINGKAT SPM/SETARAF

A. SIJIL

Semak nama sijil yang anda perolehi mengikut kod yang disediakan.

SIJIL KOD

SPM S

SPMV V

GCE G

Lain-lain L

Contoh : Jika anda memperolehi sijil SPM.

SIJIL :

B. ANGKA GILIRAN

Isikan petak-petak berkenaan dengan Angka Giliran Peperiksaan SPM/SPMV/GCE/Lain-lain yang keputusannya anda kemukakan sebagai kelayakan masuk.

Contoh : Jika angka giliran anda ialah JH025A143

ANGKA GILIRAN :

C. TAHUN PEPERIKSAAN

Isikan tahun anda menduduki peperiksaan SPM/ SPMV/GCE/Lain-lain yang keputusannya anda kemukakan sebagai kelayakan masuk.

Contoh : Jika anda menduduki peperiksaan pada tahun 2010.

TAHUN PEPERIKSAAN : D. PANGKAT (jika ada)

Semak gred atau pangkat kelulusan yang diperolehi dalam peperiksaan SPM/SPMV seperti keputusan yang anda kemukakan sebagai kelayakan masuk.

SIJIL PANGKAT KOD

SPM/SPMV

1 2 3

Sijil Am

1 2 3 4

Contoh : Jika anda memperolehi pangkat satu.

PANGKAT :

46

S

J H 0 2 5 A 1 4 3

2 0 1 0

1

BAHAGIAN A2 : MAKLUMAT AKADEMIK

E. ALIRAN

Nyatakan aliran apa yang anda ikuti semasa menduduki peperiksaan SPM atau setaraf, berpandukan kepada kod berikut :-

Contoh : Jika anda mengikuti aliran Sains.

JURUSAN : F. JENIS SEKOLAH

Jenis sekolah semasa anda menduduki peperiksaan SPM/SPMV berpandukan kod-kod berikut :-

JENIS SEKOLAH KOD

MRSM 1

Sekolah Berasrama Penuh 2

Sekolah Menengah Teknik 3

Sekolah Menengah Vokasional 4

Sekolah Menengah Agama 5

Sekolah Menengah Harian 6

Contoh : Jika anda penuntut dari Maktab Rendah Sains MARA Pontian.

JENIS SEKOLAH :

G. NAMA SEKOLAH TERAKHIR

Sila nyatakan nama sekolah yang terakhir di mana anda pernah menuntut. Ringkaskan perkataan supaya petak yang disediakan mencukupi. Ringkasan tersebut mestilah mudah difahami.

Contoh 1 : SEKOLAH MENENGAH TEKNIK TUANKU JAAFAR, NEGERI SEMBILAN

Contoh 2 : SEKOLAH MENENGAH VOKASIONAL PERDAGANGAN BUNUT SUSU Contoh 3 : MAKTAB RENDAH SAINS MARA KEM TERENDAK MELAKA Contoh 4 : SEKOLAH MENENGAH KEBANGSAAN AGAMA (L) ALAWIYAH ARAU

47

ALIRAN KOD

Sastera A

Perdagangan P

Sains S

Teknik T

Vokasional V

Lain-lain L

S

1

S M T T U A N K U J A A F A R N E G E R I S E M B I L A N

S M V P E R D A G A N G A N B U N U T S U S U

M R S M K E M T E R E N D A K M E L A K A

S M K A ( L ) A L A W I Y A H A R A U

H. KEPUTUSAN PEPERIKSAAN

Sila nyatakan gred yang anda perolehi bagi tiap-tiap mata pelajaran di peringkat SPM/SPMV.

Contoh :

BIL. MATA PELAJARAN GRED 1. BAHASA MELAYU A+ 2. BAHASA INGGERIS 1A/A 3. PENDIDIKAN ISLAM 2A/A- 4. SEJARAH 3B/B+ 5. MATEMATIK 4B/B 6. PENDIDIKAN SENI 5C/C+ 7. MATEMATIK TAMBAHAN 6C/C 8. FIZIK 7D/D 9. KIMIA 8E/E 10. BIOLOGI 9G/G 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

48

2. PERINGKAT STPM/SETARAF

A. ANGKA GILIRAN

Isikan petak-petak berkenaan dengan Angka Giliran Peperiksaan STPM yang keputusannya anda kemukakan sebagai kelayakan masuk.

Contoh : Jika angka giliran anda ialah JH025A143

ANGKA GILIRAN :

B. TAHUN PEPERIKSAAN

Isikan tahun anda menduduki peperiksaan STPM yang keputusannya anda kemukakan sebagai kelayakan masuk.

Contoh : Jika anda menduduki peperiksaan pada tahun 2010.

TAHUN PEPERIKSAAN :

C. ALIRAN

Nyatakan aliran apa yang anda ikuti semasa menduduki peperiksaan STPM.

ALIRAN KOD

Sastera A

Sains S

Contoh : Jika anda mengikuti aliran Sains.

ALIRAN :

D. NAMA SEKOLAH TERAKHIR Sila nyatakan nama sekolah yang terakhir di mana anda pernah menuntut. Ringkaskan perkataan

supaya petak yang disediakan mencukupi. Ringkasan tersebut mestilah mudah difahami.

Contoh : SEKOLAH MENENGAH KEBANGSAAN SRI GADING, BATU PAHAT, JOHOR

E. KEPUTUSAN PEPERIKSAAN

Sila nyatakan gred yang anda perolehi bagi tiap-tiap mata pelajaran di peringkat STPM

Contoh : BIL. MATAPELAJARAN GRED 1. PENGAJIAN AM A 2. MATEMATIK T B+ 3. PERDAGANGAN B+ 4. EKONOMI C 5. 6.

49

J H 0 2 5 A 1 4 3

2 0 1 0

S

S M K S R I G A D I N G B A T U P A H A T J O H O R

3. PERINGKAT SIJIL/MATRIKULASI/DIPLOMA

A. NAMA SIJIL / MATRIKULASI / DIPLOMA

Tuliskan nama Sijil /Matrikulasi /Diploma yang anda perolehi.

KELULUSAN KOD

Diploma IPTA 01

Diploma Politeknik 02

Diploma IPTS 03

Matrikulasi KPM/Asasi Sains 04

Sijil Politeknik 05

Sijil Kemahiran Malaysia Tahap 1 06





Pusat Asasi Sains UM 11

Lain-lain kelulusan 12

Contoh : Jika anda mendapat Diploma IPTA daripada Universiti Teknologi Malaysia.

NAMA SIJIL / MATRIKULASI / DIPLOMA :

B. NAMA PUSAT PENGAJIAN

Sila nyatakan nama pusat pengajian semasa anda mengikuti program peringkat Sijil/Matrikulasi/Diploma.

Contoh : Jika anda mendapat Diploma daripada Universiti Teknologi Malaysia.

C. BIDANG KELULUSAN

BIDANG KELULUSAN KOD

Sains 01

Kejuruteraan 02

Senibina 03

Ukur Bahan 04

Ukur Tanah 05

Pengurusan Harta Benda 06

Perancangan Bandar 07

Perdagangan / Perniagaan 08

Sastera 09

Pertanian 10

Perakaunan 11

Sains Fizikal 12

Sains Hayat 13

Lain-lain 14

Contoh : Jika anda mempunyai kelulusan dalam bidang mekanikal bermakna anda di dalam jurusan kejuruteraan.

BIDANG :

50

0 1

U N I V E R S I T I T E K N O L O G I M A L A Y S I A

0 2

D. PNGK/HPNM

Nyatakan PNGK/HPNM yang anda perolehi di peringkat Sijil /Matrikulasi/Diploma.

Contoh : Jika PNGK/HPNM anda di peringkat Sijil /MATRIKULASI /Diploma ialah 3.07.

PNGK/HPNM :

E. TAHUN MASUK DAN TAHUN TAMAT

Nyatakan tahun masuk ketika anda mula mengikuti pengajian di Institut Pengajian Tinggi di peringkat Sijil /Matrikulasi /Diploma.

Contoh : Jika anda mula mengikuti program Sijil di Politeknik Ungku Omar pada tahun 2006 dan tamat pada tahun 2009.

TAHUN MASUK : TAHUN TAMAT :

F. KEPUTUSAN PEPERIKSAAN MATRIKULASI

Sila nyatakan gred yang anda perolehi bagi tiap-tiap mata pelajaran di peringkat Matrikulasi

Contoh : BIL. MATAPELAJARAN GRED 1. MATEMATIK A 2. FIZIK A 3. KIMIA B 4. ENGLISH A 5. 6.

G. MALAYSIAN UNIVERSITY ENGLISH TEST (MUET)

i. Adakah anda telah menduduki ujian MUET?

STATUS KOD

Ya 1

Tidak 2

Contoh : Jika anda telah menduduki ujian MUET.

MUET : ii. Sila nyatakan Tahap Pencapaian (Band Level) dalam ujian MUET.

BAND KOD Band 1 1 Band 2 2 Band 3 3 Band 4 4 Band 5 5 Band 6 6

Contoh : Jika anda memperolehi Band 3.

BAND : iii. Tarikh keputusan

TARIKH KEPUTUSAN KOD

Mid-Year 1

End-Year 2

Contoh : Jika anda menduduki MUET Mid-Year 2009

TARIKH KEPUTUSAN : iv. Tarikh luput

Contoh : Sekiranya tarikh luput keputusan MUET anda 13 Julai 2014 (rujuk slip keputusan MUET) sila nyatakan.

51

3 . 0 7

2 0 0 6 2 0 0 9

1

3

1

A. PENGALAMAN BEKERJA

Nyatakan jawatan yang pernah /sedang disandang yang berkaitan dengan program yang anda ikuti dan tempoh perkhidmatan anda.

JAWATAN KOD

Guru 01

Pegawai Tentera (Kapten ke atas) 02

Pegawai Polis (Penolong Penguasa ke atas) 03

Pegawai Kerja (Penolong Pegawai Tadbir) 04

Pembantu Teknik 05

Pegawai Kerajaan Bahagian II 06

Kerani (Pembantu Tadbir) 07

Pembantu Tadbir (Kesetiausahaan) 08

Juruteknik 09

Anggota Tentera 10

Polis 11

Pegawai Kerajaan Bahagian III 12

Buruh 13

Pengawal Keselamatan 14

Pekerja Kilang 15

Petani dan Peladang 16

Nelayan 17

Peniaga 18

Lain-lain 19

Contoh : Jika anda bekerja sebagai Pembantu Teknik dari tarikh 1 Januari 2000 hingga 31 Disember 2009

TEMPOH

DARI HINGGA NAMA JAWATAN KOD

H H B B TAHUN H H B B TAHUN PEMBANTU TEKNIK 0 5 0 1 0 1 2 0 0 0 3 1 1 2 2 0 0 9

B. CUTI BELAJAR

KATEGORI KOD Cuti belajar bergaji penuh 1 Cuti belajar separuh gaji 2 Cuti belajar tanpa gaji 3

Contoh : Jika anda sedang bekerja dan telah mendapat kebenaran cuti belajar bergaji penuh.

CUTI BELAJAR :

52

1

BAHAGIAN A3 : MAKLUMAT PENGALAMAN BEKERJA DAN KEGIATAN LUAR

C. NAMA, ALAMAT DAN NOMBOR TELEFON MAJIKAN TERAKHIR

Sila nyatakan nama, alamat dan nombor telefon majikan terakhir anda.

Contoh : Jika alamat majikan terakhir terlalu panjang, ringkaskan perkataan supaya petak yang disediakan mencukupi. Ringkasan tersebut mestilah mudah difahami.

SETIA MAJU SDN. BHD. NO. 16, JALAN INTAN 2/2, TAMAN INTAN, 86000 KLUANG, JOHOR. NO. TELEFON : 07-4340001

POSKOD NO. TELEFON

D. KEGIATAN / AKTIVITI LUAR

Sila nyatakan kegiatan/aktiviti luar (jika berkaitan) yang pernah anda ceburi seperti sukan atau persatuan.

Contoh : Jika anda pernah menyertai Persatuan Pengguna dan memegang jawatan sebagai Setiausaha Persatuan di peringkat daerah.

BIL AKTIVITI/KEGIATAN JAWATAN PERINGKAT 1. PERSATUAN PENGGUNA SETIAUSAHA DAERAH

53

S E T I A M A J U S D N . B H D . N O . 1 6 , J L N . I N T A N 2 / 2 , T M N . I N T A N , K L U A N G , J O H O R

8 6 0 0 0 0 7 - 4 3 4 0 0 0 1

1. MAKLUMAT BAPA/IBU/PENJAGA

A. NAMA

Sila tuliskan nama bapa / ibu / penjaga dalam ruangan yang disediakan. B. NOMBOR KAD PENGENALAN/MYKAD/LAIN-LAIN PENGENALAN DIRI

Nombor kad pengenalan/MyKad/lain-lain pengenalan diri mestilah ditulis dengan tepat seperti berikut :- Contoh :

NO. KAD PENGENALAN/MYKAD/LAIN-LAIN PENGENALAN DIRI

Jika Tentera/Polis : T123456/RF1234 Jika Kad Pengenalan/MyKad : 840503-02-5555

Lain-lain (i.e.Pasport) : 0062117 C. PEKERJAAN

PEKERJAAN KOD

Doktor 01

Arkitek 02

Jurutera 03

Perancang Bandar 04

Guru 05

Pegawai Kerajaan Kumpulan A (Pengurusan Dan Profesional) 06

Pegawai Tentera (Kapten ke atas) 07

Pegawai Polis (Penolong Penguasa ke atas) 08

Pegawai Kerja (Penolong Pegawai Tadbir) 09

Pembantu Teknik 10

Pegawai Kerajaan Kumpulan B,C dan D (Sokongan) 11

Kerani (Pembantu Tadbir) 12

Pembantu Tadbir (Kesetiausahaan) 13

Juruteknik 14

Anggota Tentera 15

Polis 16

Buruh 17

Pengawal Keselamatan 18

Pekerja Kilang 19

Petani dan Peladang 20

Nelayan 21

Peniaga 22

Pesara 23

Tidak Bekerja 24

Lain-lain 25

Contoh : Jika penjaga anda bekerja sebagai Juruteknik. PEKERJAAN : JURUTEKNIK

JAWATAN : ____________________________________

Nyatakan jawatan bapa/ibu/penjaga anda di ruang yang disediakan.

54

T 1 2 3 4 5 6 8 4 0 5 0 3 - 0 2 - 5 5 5 5

0 0 0 6 2 1 1 7

1 4

BAHAGIAN B : MAKLUMAT BAPA/IBU/PENJAGA & SAUDARA

D. PENDAPATAN

Nyatakan pendapatan bulanan bapa /ibu /penjaga anda berdasarkan kod-kod berikut :-

Contoh : Jika pendapatan bapa/ibu/penjaga anda ialah RM 3500/-.

PENDAPATAN :

E. TANGGUNGAN

Tanggungan adalah tidak termasuk mereka yang sudah berumahtangga.

Contoh : Jika bilangan tanggungan penjaga adalah 7 orang.

BILANGAN TANGGUNGAN :

F. ALAMAT SURAT-MENYURAT

Nyatakan alamat pos bapa/ibu/penjaga anda di dalam ruangan yang disediakan.

Contoh : Jika alamat anda terlalu panjang, ringkaskan perkataan supaya petak yang disediakan mencukupi. Ringkasan tersebut mestilah mudah difahami.

NO. 30, LORONG SARJI, 86400 PARIT RAJA, BATU PAHAT, JOHOR. NO. TELEFON : 07-4540001 NO. TELEFON BIMBIT : 012-1234567

POSKOD NO. TELEFON

NO. TELEFON BIMBIT

55

PENDAPATAN BAPA / IBU / PENJAGA KOD

KURANG RM 1000.00 A

RM 1001/- hingga RM 2000/- B

RM 2001/- hingga RM 3000/- C

RM 3001/- hingga RM 4000/- D

RM 4001/- hingga RM 5000/- E

RM 5001/- hingga RM 6000/- F

RM 6001/- hingga RM 7000/- G

RM 7001/- hingga RM 8000/- H

RM 8001/- hingga RM 9000/- I

RM 9001/- ke atas J

D

0 7

N O . 3 0 , L O R O N G S A R J I P A R I T R A J A , B A T U P A H A T , J O H O R .

8 6 4 0 0 0 7 - 4 5 4 0 0 0 1

0 1 2 - 1 2 3 4 5 6 7

2. MAKLUMAT SAUDARA PERTAMA DAN SAUDARA KEDUA SAUDARA PERTAMA

Orang pertama yang akan dihubungi jika bapa/ibu/penjaga tidak dapat dihubungi sekiranya berlaku sebarang kes kecemasan sepanjang pengajian anda. (Jika tiada, gunakan nama dan alamat jiran ataupun sesiapa sahaja orang terdekat yang mengenali anda)

SAUDARA KEDUA

Orang kedua yang akan dihubungi jika bapa/ibu/penjaga atau saudara pertama tidak dapat dihubungi sekiranya berlaku sebarang kes kecemasan sepanjang pengajian anda.

Catatan : Pastikan saudara pertama/saudara kedua orang yang berlainan daripada bapa/ibu/penjaga.

A. NAMA

Nyatakan nama saudara pertama dan kedua di dalam ruang yang disediakan. B. HUBUNGAN

Nyatakan hubungan anda dengan saudara pertama dan kedua.

Contoh : Jika saudara pertama, bapa saudara anda. HUBUNGAN : Bapa saudara

C. NOMBOR TELEFON RUMAH

Nyatakan nombor telefon rumah saudara pertama dan kedua (jika ada). D. NOMBOR TELEFON PEJABAT

Nyatakan nombor telefon pejabat tempat di mana saudara pertama dan kedua bekerja. E. NOMBOR TELEFON BIMBIT

Nyatakan nombor telefon bimbit saudara pertama dan kedua (jika ada). F. ALAMAT

Nyatakan alamat pos saudara pertama dan kedua yang boleh dihubungi oleh pihak Universiti. 3. PENGAKUAN DAN PINDAAN MAKLUMAT

A. PENGAKUAN

Anda dikehendaki menyemak sekali lagi maklumat yang telah dilengkapkan di dalam Borang Maklumat Pelajar dengan teliti. Sila tandatangan di ruang yang disediakan, dan catatkan tarikh anda melengkapkan maklumat di dalam borang ini.

B. PEMBETULAN DAN PINDAAN MAKLUMAT

Anda diwajibkan untuk memaklumkan sebarang pembetulan dan pindaan maklumat kepada Pejabat Pengurusan Akademik. Perkara ini amat perlu dan penting kerana kemaskini perlu dilakukan pada Sistem Maklumat Pelajar.

56

ENGLISH VERSION

57

UNIVERSITI TUN HUSSEIN ONN MALAYSIA Offer for Enrolment Booklet Checklist

These are the items that you should have in your booklet :

No. Item Reference Page

1 Map to UTHM 61

2 Plan of UTHM and its Residential Colleges 63

3 Plan of UTHM’s Main Campus 65

4 Additional Conditions on the Offer for Enrolment to UTHM Appendix 1 67

5 Fees for New Students (Payments at Registration) Appendix 2A 69

6 Security Bond/Personal Bond Fee Appendix 2B 70

7 Payment Instructions for Bachelor Degree/Diploma Programmes

Appendix 3 71

8 Facilities Available in the Campus and Within the Vicinity of UTHM

Appendix 4 72

9 Requirements for the Undergraduate Orientation Week Appendix 5A 73

10 Student’s Dress Code During Registration Appendix 5B 74

11 Checklist of the Bursary Appendix 6A 75

12 Declaration Form and Request for Payment through Bank BEN/UBAP/001 76

13 Checklist of the University Health Centre (PKU) Appendix 6B 77

14 Doctor’s Certification Form UTHM.PA/PKU1 79 - 84

15 Consent for Anaesthesia and Surgery UTHM.PA/PKU2 85

16 Checklist of the Residential College Office Appendix 6C 87

17 Agreement on the Acceptance to Stay at a Residential College UTHM.PA/PDS1 89

18 Checklist of the Student Affairs Office (HEP) Appendix 6D 91

19 Guide to Completing the Student Particulars Form UTHM.PA/PPA1 93 - 113

20 Reply Card UTHM.PA/KJ

59

MAP TO UNIVERSITI TUN HUSSEIN ONN MALAYSIA (Students who plan to use the North-South Highway to UTHM are advised to use the Ayer Hitam toll exit

for your convenience)

61

UTHM

Appendix 1

OFFER FOR ENROLMENT INTO UNIVERSITI TUN HUSSEIN ONN MALAYSIA (ADDITIONAL CONDITIONS)

1. Students of Bachelor Degree programmes who did not obtain a grade of Level 3 (Band 3) in the Malaysian University English Test (MUET) at the time of receiving this offer must take this examination within the duration of your course and obtain Level 3 (Band 3) before conferment.

2. All information provided by you in your application form and your Offer for Enrolment booklet must be true.

If any of the information is found to be false, the University has the right to withdraw this offer or terminate your studies at any time.

3. You must be healthy. This must be certified using the Doctor’s Certification Form (UTHM.PA/PKU1) provided in your Offer for Enrolment booklet. The medical check-up is subject to the final verification of the University Medical Officer.

4. You are at all times subjected to the Universities and University Colleges Act 1971, Universiti Tun Hussein Onn

Malaysia (Discipline of Students) Rules and other applicable regulations at Universiti Tun Hussein Onn Malaysia. 5. You are required to attend the Nation Building Course conducted by the National Civic Bureau (BTN) or

Himpunan Patriot Negara (HIMPUN) whichever subjected by the University. 6. All first year students are required to stay in the Residential Colleges. Students who live off-campus or

opt out of staying in a Residential College are subject to the applicable University regulations. 7. The Residential College fees are subject to amendment from time to time. 8. A student whose application for deferment/medical leave in a semester is approved by University authorities is

required to pay the Residential College fees on a pro-rated basis according to the actual number of days stayed in the Residential College.

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FEES FOR NEW STUDENTS SEMESTER II 2011/2012 ACADEMICS SESSION

(PAYMENTS AT REGISTRATION)

BACHELOR DEGREE

PROGRAMMES (RM)*

DETAILS OF PAYMENT

MALAYSIAN STUDENTS

ONE –TIME FEES

1. Registration Fee 2. Alumni Fee

3. Co-curriculum Fee

4. Undergraduate Orientation Week Fee

RECURRING FEES (PER SEMESTER)

5. UTHM Service Fee 6. Tuition Fee

7. Residential College Fee

8. Insurance (per year)

20.00

100.00

200.00

130.00

180.00

700.00

479.50

-

TOTAL PAYMENT

1,809.50

* Fees Are Subject To Change Without Prior Notices And Will Be Determined By The University

69

Appendix 3

PAYMENT INSTRUCTIONS FOR BACHELOR DEGREE/DIPLOMA PROGRAMMES 1. Students are required to settle payments in full by using the cash remittance slip attached with your Offer for

Enrolment letter at any Bank Muamalat Malaysia Berhad (BMMB) branch. 2. The amount to be settled is stated on the cash remittance slip. 3. Please bring along the cash remittance slip (copy for the Bursary) endorsed by BMMB and submit it to the Bursary

Counter on the day of registration. 4. New students who are sponsored are required to submit a copy of the sponsorship letter on the day of registration. 5. Additional information :

a. If a Bank Muamalat Malaysia Berhad (BMMB) facility is not available to you or difficult for you to access, payments can be made via Bank Draft/Money Order/Postal Order made payable to “UNIVERSITI TUN HUSSEIN ONN MALAYSIA” and submitted at the Bursary counter on the day of registration.

b. New students who are applying for scholarships/loans are required to open a BMMB account at your nearest

branch. c. The University also provides the service of opening of bank accounts on the day of registration and students

who wish to open accounts are required to bring along a copy of your identity card/MyKad and a make a minimum deposit of RM20.00.

d. New students who have been given the approval to withdraw from or leave the University within 14 days of registration are eligible for a partial refund of the fees that they have paid. No refund will be made if the application to withdraw or leave is made after the above period.

e. Student who withdraw or leave after 14 days from the date of registration but have not fully settled any fees

are required to settle the unpaid fees. f. Any queries regarding problems of payment should be made to the Universiti Tun Hussein Onn Malaysia

Bursary at :

Telephone No. : 07-4537085 (Mrs. Zuhaila) or 07-4537080 (Mrs. Norhafisah) or 07-4537066 (Office) Fax No. : 07-4536040 E-mail : [email protected] or [email protected]

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Appendix 4

FACILITIES AVAILABLE IN THE CAMPUS AND WITHIN THE VICINITY OF UTHM

These are the facilities that are available in the campus and within the vicinity of UTHM: a) At the Main Campus

• UTHM Berhad Cooperative Shop

• Telesiswa Telephones and Public Telephones

• Photocopying and Binding Services

• Canteen, Cafeteria and Arcade

• Bank Muamalat Malaysia Berhad (BMMB)

• ATM Machines Kiosks (BMMB, CIMB Bank, Bank Rakyat, BSN, RHB Islamic Bank & Agro Bank)

• Student Services Kiosks

• University Health Centre

• Computer Laboratory and Internet Access

• Mini Post Office

• Sport and Recreation Facilities i) Mini Stadium and Sports Field ii) Futsal and Hockey Pitches iii) Badminton and Squash Courts iv) Gymnasium v) Golf Driving Range vi) Jogging Track vii) Wall Climbing

b) Off Campus

• CIMB Bank

• Public Bank

• Maybank

• Bank Simpanan Nasional (BSN)

• Post Office

• Government and Private Clinics

• D’ Impian Inn Hotel (07-4532744)

• Supermarket

• Police Station • KFC Restaurant • Mc Donalds Restaurant • 7-Eleven Store and others (These facilities are located within 2 kms of UTHM)

c) Accommodation available at the Batu Pahat

• Katerina Hotel (07-4337111)

• Crystal Inn Hotel (07-4315222)

• Landmarks Hotel (07-4320001)

• Silver Inn Hotel (07-4315122)

• Novo Park Hotel (07-4328787)

• Pelican Hotel (07-4328111)

• Garden Hotel (07-4315999)

• Pinetree Hotel (07-4319933)

• Rest House Batu Pahat (07-4316122) 72

Appendix 5A

REQUIREMENTS FOR THE UNDERGRADUATE ORIENTATION WEEK

BOYS 1. White long-sleeved shirt

2. Black/navy blue long trousers (no jeans)

3. Dark shoes

4. Neck tie

5. Sports attire including shoes GIRLS 1. White baju kurung blouse

2. Black/navy blue baju kurung skirt

3. Dark court shoes

4. Prayer robes (for Muslim students only)

5. Sports attire including shoes

6. White skarf

Note : i. The Residential Colleges provide bedding EXCEPT bed sheets, pillow cases and blankets.

ii. The UTHM Cooperative Shop sells daily necessities such as soap, toothbrushes, pails, slippers, etc. iii. Please ensure that you bring all other necessities.

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Appendix 5B

STUDENT’S DRESS CODE DURING REGISTRATION

Male Student

• Courteous, clean and neat attire.

• Sleeves / collared T-Shirt are allowed and must be tucked in.

• Wear slack pants.

• Wearing necktie is encouraged.

• Pair of shoes is a mandatory. Female Student

• Courteous, clean and neat attire.

• Covering the “aurat” is encouraged.

• Neat long pants are allowed.

• “Kain” or skirts must be extended beyond knee length.

• Pair of shoes is a mandatory.

STUDENT’S CONDUCT Male Student

• Short, neat hair with non artificially coloured.

• No piercing, tattooing, accessories i.e bracelet, earrings, necklace etc.

• Beard should be managed and trimmed neatly. Female Student

• Hair should be combed neatly.

• Moderate make-up, jewellery, accessory and perfume.

74

Appendix 6A

CHECKLIST BURSARY

DONE (Please tick �� if completed)

NO.

ITEM

STUDENT

BURSARY

REMARKS

1. Bank Muamalat Malaysia Berhad (BMMB) cash remittance slip

2.

Original and photostat copies of your sponsorship letter (if any)

3.

Declaration Form and Request for Payment through Bank

IMPORTANT: 1. The Offer Letter and your original documents must be brought along for verification.

2. Please attach this checklist with the items above according to its order in the checklist.

3. Please submit all these items at the Bursary counter on the day of registration. SIGNATURE : …………………………………………. NAME : …………………………………………. GENDER : …………………………………………. PROGRAMME : …………………………………………. MATRICULATION NO. : …………………………………………. DATE : ………………………………………….

TELEPHONE NO. : …………………………………………. (to contact)

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BURSARY UNIVERSITI TUN HUSSEIN ONN MALAYSIA

DECLARATION FORM AND REQUEST FOR PAYMENT THROUGH BANK

The Bursar Universiti Tun Hussein Onn Malaysia Dear Sir,

With reference to the above, I would like to request for all my Scholarship/Loan/Advance/Refund/Allowance payments to me be credited into my BMMB account as follows:

Student Savings Account No. :

2. A copy of the first page of my savings account passbook is attached. 3. I shall immediately inform the Bursary of any relevant changes to avoid any delays in payment.

4. I hereby authorise the Bursar of UTHM to request that the BMMB Manager stop payment or debit my account should there by any payment errors. If the payment has already been disbursed by the bank, then I agree to and shall return the payment to the UTHM Bursar within fourteen (14) days of receiving your demand for payment or as soon as I become aware of this error.

5. I also agree to return any Scholarship/Loan/Advance/Refund/Allowance payments if I am not entitled to it or if I had earlier declined the sponsor’s offer.

6. My failure to return the payment as required in paragraphs 4 and 5 (if applicable) shall grant the University the right to take action against me or my guarantor or both, according to the provision of the University.

I understand and I am liable for the above declaration.

Thank you.

Yours sincerely, …………………………………… (Signature) Name: ……………………………………………………… Identity Card/MyKad No/Passport No

(Please use the same identity card number as the one in your Offer for Enrolment booklet) Programme: ……………………………………… Matriculation No. :……………………………………. Name of Sponsor: ............................................. Date : …………………………………….. (if applicable) This form must be completed clearly and submitted at the UTHM Bursary counter on the day of registration.

76

BEN/UBAP/001

Appendix 6B

CHECKLIST UNIVERSITY HEALTH CENTRE (PKU)

DONE (Please tick �� if completed)

NO.

ITEM

STUDENT

PKU

REMARKS

1.

Doctor’s Certification Form (UTHM.PA/PKU1)

2.

Consent for Anaesthesia and Surgery (UTHM.PA/PKU2)

3.

X-ray film with Report

IMPORTANT: 1. The Letter of Offer and your original documents must be brought along for verification.


3. Please submit all these items at University Health Centre counter on the day of registration. SIGNATURE : ………………………………………….. NAME : ………………………………………….. GENDER : ………………………………………….. PROGRAMME : ………………………………………….. MATRICULATION NO. : ………………………………………….. DATE : ………………………………………….. TELEPHONE NO. : ………………………………………….. (to contact)

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UTHM.PA/2010/PKU1

DOCTOR’S CERTIFICATION FORM (Please submit at University Health Centre counter on the day of registration)

MATRICULATION NO. PROGRAMME CODE

79

MEDICAL CHECK-UP FOR ENROLMENT IN A STUDY PROGRAMME AT UNIVERSITI TUN HUSSEIN ONN MALAYSIA

i. You must answer ALL QUESTIONS in SECTION I before submitting this form to the doctor who is

examining you. ii. If any of the information you entered is found to be false or if you refuse to provide the required information, the

University has the right to withdraw the offer made to you for enrolment into a study programme here. iii. For SECTION II, you may choose to be seen by any government or private doctor who is able to perform all the

required examinations and tests. iv. Any payments charged for these examinations and tests shall not be borne by the University.

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SECTION I : (To be completed by the student) 1. Name of Student (IN CAPITAL LETTERS) ………………………………………………………………………. 2. Name of Father/Mother/Guardian (IN CAPITAL LETTERS) ……………………………………………………. 3. Permanent Address ……………………………………………………………………………………………….…

……………………………………………………………………………………………………………….……… ……………………………………………………………………………………………………………….………

4. Gender : Male Female

5. Marital Status : Single Married

If you are a married woman:

Are you pregnant? Yes No

6. Identity Card/MyKad No.

Old: New:

7. Date of Birth:

D D M M Y Y

8. Do you have any of the following ?

a. Tuberculosis YES / NO* b. Asthma YES / NO* c. Heart disease YES / NO* d. Mental illness YES / NO* e. Epilepsy YES / NO* f. Leprosy YES / NO* g. Physical disability YES / NO* h. Any other medical condition that requires constant care YES / NO*

If ‘YES’, please specify in full …………………………………………………….

9. Do any of your family members or relatives have any of the following ?

a. Tuberculosis YES / NO* b. Asthma YES / NO* c. Mental illness YES / NO* d. Epilepsy YES / NO* e. Leprosy YES / NO*

If ‘YES’, please specify in full …………………………………………………….

DECLARATION

I hereby declare that the statements given above are complete and true. Date: ........................................... Signature: ....................................... * Delete if not applicable.

80

SECTION II : (To be completed by the examining doctor) Note: i. If you wear spectacles, bring it along with you when you go for the medical check-up.

ii. You must undergo all examinations and tests listed in this section. The examining doctor may perform additional checks or tests if necessary.

1. General: a. Have you treated this candidate in the past? YES / NO* b. If ‘YES’, what was his/her illness and the treatment given?

.................................................................................….....................................................

c. Height ........................................ cm d. Weight ........................................ kg e. History of allergies ...................................................................…......................................... 2. Eyes:

a. Vision without spectacles Right ..............................

Left ..............................

b. Vision with spectacles Right ..............................

Left ..............................

c. Colour Vision (AT THE MOST BASIC BY USING ISHIHARA CHARTS) NORMAL / ABNORMAL* d. Funduscopy NORMAL / ABNORMAL*

If ABNORMAL, please specify ..........................................................................................................

3. Ear, Nose and Throat:

a. Hearing NORMAL / ABNORMAL*

b. Tympanic membrane NORMAL / ABNORMAL*

c. Nose NORMAL / ABNORMAL*

d. Mouth NORMAL / ABNORMAL*

e. Throat NORMAL / ABNORMAL*

f. Tonsils NORMAL / ABNORMAL*


4. Teeth: NORMAL / ABNORMAL*


.................................................................................................................…...............................................

* Delete if not applicable 81

5. Chest and Lungs:

a. Breasts NORMAL / ABNORMAL*

b. Lungs NORMAL / ABNORMAL*

c. Chest X-ray** NORMAL / ABNORMAL*


.................................................................................................................…............................................... 6. Cardiovascular:

a. Blood pressure ................................ mm Hg

b. Pulse ................................/min

c. Heart sound NORMAL / ABNORMAL*

d. Heart size NORMAL / ABNORMAL*


.................................................................................................................…............................................... 7. Abdomen:

a. Liver NORMAL / ABNORMAL*

b. Spleen NORMAL / ABNORMAL*

c. Kidney size NORMAL / ABNORMAL*

d. Other NORMAL / ABNORMAL*


.................................................................................................................…...............................................

8. Genitalia: NORMAL / ABNORMAL*


.................................................................................................................…............................................... 9. Mascularskeletal:

a. Spine NORMAL / ABNORMAL*

b. Upper limbs NORMAL / ABNORMAL*

c. Lower limbs NORMAL / ABNORMAL*

d. Reflexes NORMAL / ABNORMAL*

e. Sensory NORMAL / ABNORMAL*


.................................................................................................................…...............................................

* Delete if not applicable ** Chest X-ray must be attached.

82

10. Urine tests

a. S. Gravity NORMAL / ABNORMAL* b. Albumin PRESENT/ABSENT* c. Glucose PRESENT/ABSENT* d. Microscopic NORMAL / ABNORMAL* If PRESENT or ABNORMAL, please specify ..........................................................................................................

............................................................................................................................................................ 11. Urine test for DRUGS: NEGATIVE / POSITIVE

(Morphine & Cannabinoid) 12. Other Tests .............................................................................................................................................................

.............................................................................................................................................................

* Delete if not applicable.

83

CERTIFICATION OF EXAMINING DOCTOR I have examined Mr / Mrs / Miss ……………………………………………….………………………………………………. and hereby certify that the information in SECTION I is true. I find these conditions in him/her to be:

NO. CONDITION PRESENT ABSENT

1.

Infectious diseases

2.

Mental illness

3.

Physical disability

4.

Has a medical condition other than the above

I am of the opinion that he/she needs:

NO. FOLLOW-UP NECESSARY NOT

NECESSARY

1.

Follow-up treatment

2.

Referral to a specialist

If PRESENT or NECESSARY, please specify ..........................................................................................................

…………………………………………………………………………………………………………………...

…………………………………………………………………………………………………………………...

……………………………………………………………………………………………………………………

Date: ..................................... Signature : ……………………………….

Name : ……………………………….

Designation : ……………………………….

Name of Hospital/Clinic : ………………………………. (Official Stamp)

84

UTHM.PA/PKU2

CONSENT FOR ANAESTHESIA AND SURGERY (For candidates below 21 years of age)

(Please submit this form at the University Health Centre counter on the day of registration) Medical Officer Universiti Tun Hussein Onn Malaysia I, ………………………………………………… Identity Card/MyKad No/Passport No ……………………………………..

the father/mother/guardian of (name of student) ………………………………………………………... hereby authorise you to

sign the consent on my behalf if in your view, he/she requires anaesthesia/surgery urgently.

Yours sincerely, ……………………………………………. (Signature of father/mother/guardian) Date: …………………………………... Name of father/mother/guardian

…………………………………………….

Address: ……………………………………

…………………………………………….

…………………………………………….

Telephone No.: ………………………...

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Appendix 6C

CHECKLIST RESIDENTIAL COLLEGE OFFICE

FOLLOW-UP (Please tick �� if completed)

NO.

ITEM

STUDENT

RESIDENTIAL COLLEGE

REMARKS

1. Agreement on the Acceptance to Stay at a Residential College for the _______________ Academic Session (UTHM.PA/PDS1)

2. Two (2) passport-sized photographs (in colour) with your name and identity card / passport number written on the back

IMPORTANT: 1. Your Offer Letter and your original documents must be brought along for verification.


3. Please submit all these items at the Residential College Office counter on the day of registration.

SIGNATURE : ………………………………………….. NAME : ………………………………………….. GENDER : ………………………………………….. FACULTY : ………………………………………….. MATRICULATION NO. : ………………………………………….. DATE : ………………………………………….. TELEPHONE NO. : ………………………………………….. (to contact)

87

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UTHM.PA/PDS1

AGREEMENT ON ACCEPTANCE TO STAY AT A RESIDENTIAL COLLEGE FOR THE ____________________ ACADEMIC SESSION

I, ………………………………………... Identity Card/MyKad No/Passport No………………………….. hereby accept the

offer by Universiti Tun Hussein Onn Malaysia (UTHM) to stay at a Residential College, UTHM for a period of one (1) year of my

study session effective from the date stated below and I agree to comply with the following conditions:

1. I shall observe the provisions of the Universities and College Universities Act 1971, Universiti Tun Hussein Onn

Malaysia (Discipline of Students) Rules, all applicable regulations of Universiti Tun Hussein Onn Malaysia (UTHM),

all applicable regulations of the Residential College and any other regulations and orders that may be issued from time

to time.

2. I shall give my cooperation and commitment in all activities of the Residential College.

3. I will settle all fees of the Residential College and any other payments required of me throughout the duration of my

contract.

4. I agree that my Residential College fees will not be refunded if I leave the Residential College within the stipulated

period or if I am ordered to leave the Residential College as a result of disciplinary action taken against me.

5. I will bear any claims for damages or any penalty imposed upon me if I violate any of the regulations of the

Residential College.

6. I shall indemnify the Residential College on any claims arising out of my own negligence.

Yours sincerely, Witness:

Signature of student : ……………………… Signature : ………………………..

Name of father/mother/guardian

…………………………………………….

Date : ……………………….. Date : …………………………………

Telephone No. (Home): …………………….

Telephone No. (Mobile): ………………………..

89

ROOM NO.

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Appendix 6D

CHECKLIST STUDENT AFFAIRS OFFICE (HEP)

DONE

(Please tick �� if you received the item on the day of registration)

NO.

ITEM

STUDENT

HEP

REMARKS

1.

Batik shirt

2.

Long Sleeve Collard T-shirt

3.

Bag

4.

Student’s handbook

IMPORTANT: 1. The Offer Letter and your original documents must be brought along for verification.

2. Please submit this checklist at the Student Affairs Office counter on the day of registration. SIGNATURE : ………………………………………….. NAME : ………………………………………….. GENDER : ………………………………………….. PROGRAMME : ………………………………………….. MATRICULATION NO. : …………………………………………. DATE : ………………………………………….. TELEPHONE NO. : ………………………………………….. (to contact)

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A GUIDE TO COMPLETING THE STUDENT PARTICULARS FORM Form UTHM. PA/PPA1

(Form is included in the Undergraduate File)

1. The details given in the (UTHM.PA/PPA1) Form is very important and will be updated in UTHM’s Student Information System.

2. Please complete the Student Particulars Form (UTHM.PA/PPA1) using a black/blue

ballpoint pen. 3. Please use CAPITAL LETTERS when writing within the boxes or on the lines

provided. 4. Please ensure that all particulars given is complete and accurate before confirming its

validity in the declaration section.

93

1. NAME Your name must be written exactly as it appears on your identity card/MyKad. Write your name in CAPITAL LETTERS in

the boxes provided. Use one box for each letter and leave blank a box in between two words. Example : If your name is MOHD. HASRIZAL BIN MOHD. HARITH, NAME :

M O H D . H A S R I Z A L B I N M O H D . H A R I T H If there are not enough boxes, use abbreviations to fit within the number of boxes provided but they must be easily understood. Example: If your name is TENGKU INTAN BINTI TENGKU MOHD. KASIM, NAME :

T G . I N T A N B T . T G . M O H D K A S I M 2. ALIAS Specify other name that you are known as apart from your real name (if any). Example : If your name is LIM KAR CHAI and you are also known as JASON LIM, ALIAS :

3. IDENTITY CARD/MYKAD/OTHER IDENTIFYING DOCUMENT NUMBER The identity card/MyKad/other identifying document number must be written accurately, as follows:- Example: IDENTITY CARD/MYKAD/OTHER IDENTIFYING DOCUMENT NUMBER

Army/Police personnel : T123456/RF1234 12-digit MyKad numbers : 880503-02-5555 Other (e.g. Passport) : 0062117

4. MATRICULATION NO. Write the matriculation number that is issued to you by the University. This number is stated in your Offer Letter and shall

be your identification number at the University. You are required to carefully keep and remember your matriculation number.

Example : If your matriculation number is AF110001, MATRICULATION NO. :

95

J A S O N L I M

T 1 2 3 4 5 6 8 8 0 5 0 3 - 0 2 - 5 5 5 5 0 0 0 6 2 1 1 7

A F 1 1 0 0 0 1

SECTION A1 : PERSONAL PARTICULARS

5. FACULTY

FACULTY CODE

Faculty of Civil and Environmental Engineering 01 Faculty of Electrical and Electronic Engineering 02 Faculty of Mechanical and Manufacturing Engineering 03 Faculty of Technology Management, Business and Enterpreneurship 04 Faculty of Technical Education 05 Faculty of Science Computer and Information Technology 06 Faculty of Science, Technology and Human Development 07 Centres of Diploma Studies 08

Example : If the faculty you are in is the Faculty of Civil and Environmental Engineering (please refer to your Offer Letter),

FACULTY :

6. PROGRAMME CODE

PROGRAMME

CODE

BACHELOR DEGREES Faculty of Civil and Environmental Engineering (FKAAS) Bachelor of Civil Engineering with Honours Faculty of Electrical and Electronic Engineering (FKEE) Bachelor of Electrical Engineering (Power System) with Honours Bachelor of Electronic Engineering (Communication) with Honours Bachelor of Electronic Engineering (Computer Engineering) with Honours Bachelor of Electronic Engineering (Mechatronic) with Honours Bachelor of Electronic Engineering (Microelectronic) with Honours Bachelor of Electronic Engineering (Medical Electronic) with Honours Faculty of Mechanical and Manufacturing Engineering (FKMP) Bachelor of Mechanical Engineering with Honours Bachelor of Aeronautical Engineering Technology (Profesional Piloting) with Honours Bachelor of Aeronautical Engineering Technology (Aircraft Maintenance) with Honours Faculty of Technology Management, Business and Enterpreneurship (FPTPK) Bachelor of Technology Management with Honours Bachelor of Technology Management (Production and Operation) with Honours Bachelor of Technology Management (Construction) with Honours Bachelor of Property Management with Honours Faculty of Technical Education (FPTek) Bachelor of Vocational Education (Electrical & Electronic) with Honours Bachelor of Education (Primary School) with Honours Bachelor of Technical and Vocational Education Faculty of Science Computer and Information Technology (FSKTM) Bachelor of Information Technology Faculty of Science, Technology and Human Development (FSTPI) Bachelor of Science (Applied Physics) with Honours Bachelor of Science (Industrial Statistics) with Honours Bachelor of Science (Food Technology) with Honours Bachelor of Science (Mathematics Technology) with Honours

BFF

BEF BEB BEC BEH BED BEU

BDD BDC BDM

BPA BPB BPC BPD

BBE BBR BBV

BIT

BWA BWB BWC BWD

0 1

96

PROGRAMME

CODE

DIPLOMAS Centres of Diploma Studies (PPD) Diploma in Civil Engineering Diploma in Civil Engineering with Technology Diploma in Electrical Engineering Diploma in Electrical Engineering with Technology Diploma in Mechanical Engineering Diploma in Mechanical Engineering with Technology Diploma in Information Technology

DAA DAC DAE DAL DAM DAI DAT

Example 1: If you are entering the Bachelor of Civil Engineering with Honours programme, enter code BFF. PROGRAMME CODE :

Example 2: If you are entering the Diploma in Electrical Engineering with Technology programme, enter code DAL.

PROGRAMME CODE :

7. DATE OF BIRTH Example : If you were born on 13 May 1988,

DATE OF BIRTH :

D D M M YEAR 8. GENDER

GENDER CODE

Male M

Female F

Example: : If you are female, GENDER :

97

B F F

D A L

1 3 0 5 1 9 8 8

P

9. RACE

RACE CODE RACE CODE RACE CODE

Malay 0100 Tambanuo 0925 Lemanak 1118 Chinese 0200 Tagal 0926 Lahanan 1119 Indian 0300 Tinagas 0927 Lusum/Lugum 1120 Indian Muslim 0307 Cocos 0928 Matu 1121 Indonesian 0700 Kimaragang 0929 Maloh 1122 Sabahan Bumiputera 0800 Bolongan 0930 Melikin 1123 Bajau 0801 Buton 0931 Melaing 1124 Dusun 0802 Sarawakian Bumiputera 1000 Murik 1125 Kadazan 0803 Sarawakian Malay 1001 Menondo 1126 Murut 0804 Melanau 1002 Nyamok 1127 Sino-Native 0805 Kedayan 1003 Sebob 1128 Suluk 0806 Iban/Sea Dayak 1004 Seduan 1129 Binadan 0901 Bidayuh/Land Dayak 1005 Sekapan 1130 Bisaya 0902 Kayan 1006 Segalang 1131 Bongol 0903 Kenyah 1007 Sian 1132 Bruneian 0904 Murut/Lun Bawang 1008 Sipeng 1133 Dumpas 0905 Kelabit 1009 Saribas 1134 Irranun 0906 Penan/Punan 1010 Sebuyau 1135 Idahan 0907 Bisaya 1101 Skrang 1136 Kwijau 0908 Berawan 1102 Sabahan 1137 Kedayan 0909 Belot 1103 Selakan 1138 Lingkabau 0910 Bukit 1104 Selakau 1139 Lundayeh 0911 Balau 1105 Tagal 1140 Lasau 0912 Batang Ai 1106 Tabun 1141 Melanau 0913 Batu Elah 1107 Tutong 1142 Mangkaak 0914 Bukitan 1108 Tanjong 1143 Matagang 0915 Bintulu 1109 Tatau 1144 Minokok 0916 Badang 1110 Taup 1145 Momogun 0918 Dusun 1111 Ukit 1146 Paitan 0919 Jagoi 1112 Umkop 1147 Ramanau 0920 Kiput 1113 Ulu Ai 1148 Rungus 0921 Kajang 1114 Orang Asli (Peninsular) 1200 Sungai 0922 Kajaman 1115 Arab 1301

Sonsongan 0923 Kanowit 1116 Khmer (Cambodia) 1308 Sinulahan 0924 Lirong 1117 Other 1400 Example: If you are a Malay, RACE :

10. RELIGION

RELIGION CODE

Islam I

Christian K

Buddhism B

Hinduism H

Other L

Example: If you are a Muslim,

RELIGION :

98

0 1 0 0

I

11. STATE OF BIRTH

STATE CODE STATE CODE STATE CODE

Perak A Pulau Pinang U Sarawak Y

Selangor B Perlis R Other L

Pahang C Terengganu T Kelantan D

Sabah E

Federal Territory of Kuala Lumpur W

Johor J

Kedah K

Federal Territory of Labuan V

Melaka M

Negeri Sembilan N

Federal Territory of Putrajaya P

Example: If you were born in the state of Selangor, STATE OF BIRTH :

12. STATE OF RESIDENCE Specify the state you now reside in by using the State of Birth code.

Example: If you are now living in the state of Johor, STATE OF RESIDENCE :

13. CITIZENSHIP

CITIZEN OF CODE

Malaysia M

The Philippines F

Indonesia I

Singapore S

Thailand T

Brunei Darussalam U

Temporary Resident P

Permanent Resident E

Other L

Example: If you are a Malaysian, CITIZENSHIP :

14. HEIGHT

HEIGHT CODE

144 centimetres (4 feet 9 inches) or taller 1

144 centimetres (4 feet 9 inches) or shorter 2

Example: If you are taller than 144cm (4 feet 9 inches or taller),

HEIGHT :

99

B

J

M

1

15. DISABILITY Are you a disabled person?

DISABLED CODE

Yes 1

No 2

Example: If you are a disabled person (OKU), DISABILITY :

16. COLOUR BLINDNESS

COLOUR BLINDNESS CODE

Yes 1

No 2

Example: If you are colour blind, COLOUR BLINDNESS :

17. MARITAL STATUS

Example: If you are single, MARITAL STATUS

18. DATE OF MARRIAGE

Example: If you were married on 4 January 1999,

DATE OF MARRIAGE : D D M M YEAR

19. STUDENT DUN AREA Please state student DUN area 20. STUDENT PARLIMENT AREA Please state student Parliment area 21. SCHOLARSHIPS/LOANS VALUE OF SCHOLARSHIP/LOAN Specify the Scholarship/Loan offered to you and its value (if applicable)

100

1

1

MARITAL STATUS CODE

Single 1

Married 2

Divorced/Widowed 3

1

0 4 0 1 1 9 9 9

22. PERMANENT ADDRESS

Your permanent address is the address of your permanent residence. Example: If your address is too long, abbreviate the words to fit into the boxes provided. These abbreviations must be

easily understood. NO. 6, BLOK 5, JALAN 9/106F, FLAT SRI JOHOR, BATU 3 1/2, JALAN CHERAS, 50400 KUALA LUMPUR. TELEPHONE NO. : 03-12345678 HANDPHONE NO. : 012-1234567

POSTCODE TELEPHONE NO.

HANDPHONE NO.

23. ADDRESS DURING STUDY (ADDRESS OF RESIDENTIAL COLLEGE):

Example: If your address is too long, abbreviate the words to fit into the boxes provided. These abbreviations must be

easily understood. G5D-101, KOLEJ KEDIAMAN TUN FATIMAH, UNIVERSITI TUN HUSSEIN ONN MALAYSIA, 86400 PARIT RAJA, BATU PAHAT, JOHOR.

TELEPHONE NO. : 07-4540001 HANDPHONE NO. : 012-1234567

POSTCODE TELEPHONE NO. HANDPHONE NO.

NOTE:

If you change your permanent or postal address, you may update it in the Student Information System (SMP) by completing the change of address form available at the Academic Management Office. You can update your current address yourself during your period of study using the SMP. Your failure to do so will disrupt any correspondence to you, such as those on your conferment.

101

N O . 6 , B L O K 5 , J A L A N 9 / 1 0 6 F ,

F L A T S R I J O H O R , B T . 3 1 / 2 , J A L A N C H E R A S , K U A L A L U M P U R .

5 0 4 0 0 0 3 - 1 2 3 4 5 6 7 8

0 1 2 - 1 2 3 4 5 6 7

G 5 D - 1 0 1 , K O L E J K E D I A M A N T U N F A T I M A H ,

U N I V T U N H U S S E I N O N N M A L A Y S I A , P A R I T R A J A , B A T U P A H A T , J O H O R .

0 7 - 4 5 4 0 0 0 1 8 6 4 0 0

0 1 2 - 1 2 3 4 5 6 7

1. SPM OR ITS EQUIVALENT

A. CERTIFICATE Refer to the codes below to specify the certificates you have obtained.

CERTIFICATE CODE

SPM S

SPMV V

GCE G

Other L

Example: If you passed SPM, CERTIFICATE:

B. CANDIDATE NUMBER Fill in the boxes provided with your Candidate Number for the SPM/SPMV/GCE/Other examination that you are

using as entry qualification.

Example: If your candidate number was JH025A143,

CANDIDATE NUMBER :

C. YEAR OF EXAMINATION Fill in the year you sat for the SPM/SPMV/GCE/Other examination that you are using as entry qualification.

Example: If you sat for the examination in 2010,

YEAR OF EXAMINATION: D. GRADE (if applicable) Refer to these codes to specify the grade or level obtained in the SPM/SPMV examination that you are using as entry

qualification.

CERTIFICATE GRADE CODE

SPM/SPMV

1 2 3

General Certificate

1 2 3 4

Example: If you obtained grade one,

GRADE:

102

S

J H 0 2 5 A 1 4 3

2 0 1 0

1

SECTION A2 : ACADEMIC BACKGROUND

E. STREAM Specify the stream you were in when you sat for your SPM examination or its equivalent, by using the following

codes:-

Example: If you were in the Science stream,

STREAM: F. TYPE OF SCHOOL

Fill in the type of school you attended when you sat for the SPM/SPMV examination using the following codes:-

TYPE OF SCHOOL CODE

MRSM 1

Fully Residential School 2

Secondary Technical School 3

Secondary Vocational School 4

Secondary Religious School 5

Regular Secondary School 6

Example: If you had been a student of the MRSM in Pontian,

TYPE OF SCHOOL:

G. NAME OF LAST SCHOOL

Write the name of the school you last attended. Abbreviate the word if necessary to fit within the boxes provided. These abbreviations must be easily understood.

Example 1: SEKOLAH MENENGAH TEKNIK TUANKU JAAFAR, NEGERI SEMBILAN

Example 2: SEKOLAH MENENGAH VOKASIONAL PERDAGANGAN BUNUT SUSU Example 3: MAKTAB RENDAH SAINS MARA KEM TERENDAK MELAKA Example 4: SEKOLAH MENENGAH KEBANGSAAN AGAMA (L) ALAWIYAH ARAU

103

STREAM CODE

Arts A

Commerce P

Science S

Technical T

Vocational V

Other L

S

1

S M T T U A N K U J A A F A R N E G E R I S E M B I L A N

S M V P E R D A G A N G A N B U N U T S U S U

M R S M K E M T E R E N D A K M E L A K A

S M K A ( L ) A L A W I Y A H A R A U

H. EXAMINATION RESULTS Write the grade you obtained for each subject in the SPM/SPMV examination.

Example:

NO. SUBJECT GRADE

1. BAHASA MELAYU A+ 2. ENGLISH LANGUAGE 1A/A 3. ISLAMIC STUDIES 2A/A- 4. HISTORY 3B/B+ 5. MATHEMATICS 4B/B 6. ART 5C/C+ 7. ADDITIONAL MATHEMATICS 6C/C 8. PHYSICS 7D/D 9. CHEMISTRY 8E/E 10. BIOLOGY 9G/G 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

104

2. STPM OR ITS EQUIVALENT

A. CANDIDATE NUMBER Fill in the boxes provided with your Candidate Number for the STPM examination that you are using as entry

qualification.

Example: If your candidate number was JH025A143, CANDIDATE NUMBER :

B. YEAR OF EXAMINATION Fill in the year you sat for the STPM examination that you are using as entry qualification.

Example: If you sat for the examination in 2010,

YEAR OF EXAMINATION :

C. STREAM Specify the stream you were in when you sat for your STPM examination by using the following codes:-

STREAM CODE

Arts A

Science S

Example: If you were in the Science stream,

STREAM:

D. NAME OF LAST SCHOOL Write the name of the school you last attended. Abbreviate the word if necessary to fit within the boxes provided.

These abbreviations must be easily understood.

Example: SEKOLAH MENENGAH KEBANGSAAN SRI GADING, BATU PAHAT, JOHOR

E. EXAMINATION RESULTS Write the grade you obtained for each subject in the STPM examination.

Example: NO. SUBJECT GRADE

1. GENERAL STUDIES A

2. ADDITIONAL MATHEMATICS B+

3. COMMERCE B+

4. ECONOMICS C

5.

105

J H 0 2 5 A 1 4 3

2 0 1 0

S

S M K S R I G A D I N G B A T U P A H A T J O H O R

3. CERTIFICATE/MATRICULATION/DIPLOMA OR ITS EQUIVALENT

A. NAME OF CERTIFICATE/MATRICULATION/DIPLOMA Write the name of the Certificate/Matriculation/Diploma that you obtained.

QUALIFICATION CODE

Diploma from an IPTA 01

Diploma from a Polytechnic 02

Diploma from an IPTS 03

KPM Matriculation/Science Foundation 04

Certificate from a Polytechnic 05

Malaysian Skill Certificate Level 1 06





UM Centre for Foundation Studies in Science 11

Other qualifications 12

Example: If you obtained an IPTA Diploma from Universiti Teknologi Malaysia,

NAME OF CERTIFICATE/MATRICULATION/DIPLOMA:

B. NAME OF EDUCATIONAL CENTRE

Write the name of the educational centre that you attended for the Certificate/Matriculation/Diploma programme. Example: If you obtained a Diploma from Universiti Teknologi Malaysia,

C. FIELD OF QUALIFICATION

FIELD OF QUALIFICATION CODE

Science 01

Engineering 02

Architecture 03

Quantity Survey 04

Land Survey 05

Property Management 06

Town Planning 07

Commerce/Business 08

Arts 09

Agriculture 10

Accounting 11

Physical Sciences 12

Biological Sciences 13

Other 14

Example: If you have a qualification in mechanics, then your field of qualification is engineering.

FIELD:

106

0 1

U N I V E R S I T I T E K N O L O G I M A L A Y S I A

0 2

D. CUMULATIVE GRADE POINT AVERAGE (CGPA) Specify the CGPA you obtained for your Certificate/Matriculation/Diploma.

Example: If the CGPA you obtained at Certificate/Matriculation/Diploma level is 3.07, CGPA:

E. YEARS OF ENTRY AND COMPLETION Specify the year you enrolled at the Institute of Higher Education where you underwent the

Certificate/Matriculation/Diploma programme and the year you completed the programme.

Example: If you started the Certificate programme at Politeknik Ungku Omar in 2006 and completed it in 2009,

YEAR OF ENTRY :

YEAR OF COMPLETION:

F. MATRICULATION EXAMINATION RESULTS Write the grade you obtained for each subject in the Matriculation examination.

Example: NO. SUBJECT GRADE 1. MATHEMATICS A 2. PHYSIC A 3. CHEMISTRY B 4. ENGLISH A 5.

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3 . 0 7

2 0 0 6

2 0 0 9

G. MALAYSIAN UNIVERSITY ENGLISH TEST (MUET)

i. Did you sit for the MUET test?

STATUS CODE

Yes 1

No 2

Example : If you took the MUET test, MUET :

ii. Specify the Band Level you obtained in the MUET test.

BAND CODE

Band 1 1 Band 2 2 Band 3 3 Band 4 4 Band 5 5 Band 6 6

Example : If you obtained Band 3,

BAND : iii. Date of Results

Date of Results KOD

Mid-Year 1

End-Year 2

Example : If you took the MUET Mid-Year 2009 DATE OF RESULTS : iv. Date of Expiry

Example : Please state your expiration date for MUET result i.e. 13 July 2014 (on printed on the MUET result slip)

108

1

3

1

A. WORKING EXPERIENCE

Specify any post previously/currently held that is related to the programme you are taking and the tenure of your service.

DESIGNATION CODE

Teacher 01

Army Officer (Captain or higher) 02

Police Officer (Assistant Commissioner or higher) 03

Works Officer (Assistant Administrative Officer) 04

Technical Assistant 05

Division II Government Officer 06

Clerk (Administrative Assistant) 07

Administrative Assistant (Secretarial) 08

Technician 09

Army Personnel 10

Policeman 11

Division III Government Officer 12

Labourer 13

Security Guard 14

Factory Worker 15

Planter or Farmer 16

Fisherman 17

Businessman 18

Other 19

Example: If you worked as a Technical Assistant from 1 January 2000 to 31 December 2009,

PERIOD

FROM TO DESIGNATION CODE

D D M M YEAR D D M M YEAR

TECHNICAL ASSISTANT

0 5 0 1 0 1 2 0 0 0 3 1 1 2 2 0 0 9

B. STUDY LEAVE

CATEGORY CODE

Study leave with full salary 1 Study leave with half salary 2 Study leave without salary 3

Example: If you are still employed and have obtained approval for study leave with full salary, STUDY LEAVE :

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1

SECTION A3 : WORKING EXPERIENCE AND CO-CURRICULAR ACTIVITIES

C. NAME, ADDRESS AND TELEPHONE NUMBER OF LAST EMPLOYER

Please provide the name, address and telephone number of your last employer.

Example: If the address of your last employer is too long, abbreviate the words to fit into the boxes provided. These abbreviations must be easily understood.

SETIA MAJU SDN. BHD. NO. 16, JALAN INTAN 2/2, TAMAN INTAN, 86000 KLUANG, JOHOR. TELEPHONE NO. 07-4340001


D. CO-CURRICULAR ACTIVITIES

Please list down any extracurricular activities that you have participated in, such as sports or memberships in associations.

Example: If you were a member of the Consumers’ Association in which you held the post of Association

Secretary at district level,

NO. ACTIVITY DESIGNATION LEVEL

1. CONSUMERS’ ASSOCIATION SECRETARY DISTRICT

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S E T I A M A J U S D N . B H D . N O . 1 6 , J L N . I N T A N 2 / 2 , T M N . I N T A N , K L U A N G , J O H O R

8 6 0 0 0 0 7 - 4 3 4 0 0 0 1

1. FATHER/MOTHER/GUARDIAN

A. NAME Write the name of your father/mother/guardian in the space provided. B. IDENTITY CARD/MYKAD/OTHER IDENTIFYING DOCUMENT NUMBER

The identity card/MyKad/other identifying document number must be written accurately, as follows:- Example:

IDENTITY CARD/MYKAD/OTHER IDENTIFYING DOCUMENT NUMBER

Army/Police personnel : T123456/RF1234 Identity Card/MyKad : 840503-02-5555

Other (e.g. Passport) : 0062117

C. OCCUPATION

OCCUPATION CODE

Doctor 01

Architect 02

Engineer 03

Town Planner 04

Teacher 05

Category A (Management and Professional) Government Officer 06

Army Officer (Captain or higher) 07

Police Officer (Assistant Commissioner or higher) 08

Works Officer (Assistant Administrative Officer) 09

Technical Assistant 10

Category B, C or D (Support) Government Officer 11

Clerk (Administrative Assistant) 12

Administrative Assistant (Secretarial) 13

Technician 14

Army Personnel 15

Policeman 16

Labourer 17

Security Guard 18

Factory Worker 19

Planter or Farmer 20

Fisherman 21

Businessman 22

Pensioner 23

Unemployed 24

Other 25

Example: If your parent/guardian works as a Technician. PROFESSION : TECHNICIAN

DESIGNATION : ____________________________________ Write the designation of your father/mother/guardian in full in the space provided.

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T 1 2 3 4 5 6 8 4 0 5 0 3 - 0 2 - 5 5 5 5 0 0 0 6 2 1 1 7

1 4

SECTION B : PARENTS/GUARDIAN & NEXT-OF-KIN

D. INCOME Specify the monthly income of your father/mother/guardian using the following codes:-

INCOME OF FATHER/MOTHER/GUARDIAN CODE

Less than RM 1000 A

RM 1001 to RM 2000 B

RM 2001 to RM 3000 C

RM 3001 to RM 4000 D

RM 4001 to RM 5000 E

RM 5001 to RM 6000 F

RM 6001 to RM 7000 G

RM 7001 to RM 8000 H

RM 8001 to RM 9000 I

RM 9001 and above J

Example: If the income of your father/mother/guardian is RM 3500 a month,

INCOME:

E. DEPENDANTS Dependants do not include those who are married.

Example: If the number of dependants is 7.

NO. OF DEPENDANTS:

F. POSTAL ADDRESS

Write the postal address of your father/mother/guardian in the space provided.

Example: If your address is too long, abbreviate the words to fit into the boxes provided. These abbreviations must be easily understood.

NO. 30, LORONG SARJI,

86400 PARIT RAJA, BATU PAHAT, JOHOR. TELEPHONE NO. : 07-4540001 HANDPHONE NO. : 012-1234567


HANDPHONE NO.

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D

0 7

N O . 3 0 , L O R O N G S A R J I P A R I T R A J A , B A T U P A H A T ,

J O H O R .

0 7 - 4 5 4 0 0 0 1 8 6 4 0 0

0 1 2 - 1 2 3 4 5 6 7

2. NEXT-OF-KIN FIRST NEXT-OF-KIN

The first person to be contacted if your father/mother/guardian cannot be contacted in case of emergency during the period of your study (if none, use the name and address of a neighbour or anyone close to you).

SECOND NEXT-OF-KIN

The second person to be contacted if your father/mother/guardian or your first next-of-kin cannot be contacted in case of emergency during the period of your study

Note: The first and second next-of-kin must not be your father/mother/guardian.

A. NAME Write the names of your first and second next-of-kin in the spaces provided.

B. RELATIONSHIP Specify your relationship with your first and second next-of-kin.

Example : If the first next-of-kin is your uncle, RELATIONSHIP : Uncle

C. HOME TELEPHONE NUMBER Write the home telephone number (if any) of your first and second next-of-kin. D. OFFICE TELEPHONE NUMBER Write the telephone number of the office where your first and second next-of-kin work.

E. HANDPHONE NUMBER Write the mobile telephone number (if any) of your first and second next-of-kin.

F. ADDRESS Write the postal address of your first and second next-of-kin for contact by the University.

3. DECLARATION AND AMENDMENTS TO INFORMATION A. DECLARATION

You are required to carefully review the information entered into your Student Particulars Form. Please sign in the

space provided, and write the date you entered the details in the form.

B. CORRECTIONS AND AMENDMENTS TO INFORMATION You are required to inform the Academic Management Office of any corrections or amendments to your particulars.

This is most necessary and important for updating the Student Information System.

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Matriculation No. : Name: ………………………………………………………………..

Identity Card/MyKad No.: Address: ……………………………………………………………….. ……………………………………………………………….

………………………………………………………………..

………………………………………………………………..

Senior Deputy Registrar Date: ………………………… Academic Management Office Universiti Tun Hussein Onn Malaysia

Dear Sir,

OFFER FOR ENROLMENT INTO UNIVERSITI TUN HUSSEIN ONN MALAYSIA

NAME OF PROGRAMME: ……………………………………………………………………………………………………………………………

I am pleased to accept your offer for enrolment into the programme above. I agree to the conditions stipulated and understand that this programme offered to me is final. I will report on the date given.

OR

I regret that I would like to decline your offer for enrolment because (please specify…………………………………………………………………... ……………………………………………………………………… Yours sincerely, ........................................ (Signature)

Note: i) Please tick (��) the relevant box ii) This reply must be returned to UTHM IMMEDIATELY

Reply Card

UTHM.PA/KJ C

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Senior Deputy Registrar Academic Management Office Universiti Tun Hussein Onn Malaysia 86400 Parit Raja, Batu Pahat, JOHOR.

Tel. No. : 07-4537681/7686/7687/7689/7655 Fax No. : 07-4536085 E-Mail : [email protected]

Published by: Academic Management Office Universiti Tun Hussein Onn Malaysia 86400 Parit Raja, Batu Pahat, JOHOR.

UTHM.PA/KJ

Reply Card

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