UKM/PPPS/C/P03/AK05/01Tarikh Kuatkuasa 01-03-2010

PUSAT PENGURUSAN SISWAZAHPERMOHONAN MENDAFTAR LEWAT

Centre for Graduate ManagementApplication for late registration

Bahagian A: Maklumat Diri Pelajar Part A: Student’s Details

Nama (Name)

No. Pendaftaran(Registration Number)

Alamat tetap(Permanent Address)

No. Telefon (Telephone number)

Alamat surat menyurat(Correspondence address)

No. Telefon Waris/Jiran/Kawan(Telephone number of nearestrelative/friends/neighbour)

No. Faksimili(Fax. No.)

Emel (E-mail)

Program pengajian (Program) : Sarjana / Doktor Falsafah* (Masters / Doctor of Philosophy)Bentuk pendaftaran(Type of registration) : Sepenuh Masa / Separuh Masa* (Full time / Part time)Pusat pengajian/Jabatan : ______________________________________________(School/Department)Fakulti (Faculty) : _________________________________________

Tarikh mula daftar (Date of registration) :Semester ________ Sesi ________

Tarikh jangka tamat (Expected date of completion) :Semester ________ Sesi ________

Tarikh permohonan daftar semester semasa : ________________________________(Applied date to register for the current semester)

Sebab-sebab memohon daftar lewat (Reasons for late registration) : _____________________________________

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Tandatangan (Signature) : _________________ Tarikh(Date) : ___________

[*Potong yang tidak berkenaan(Delete where not applicable)]

UKM/PPPS/C/P03/AK05/01Tarikh Kuatkuasa 01-03-2010

Bahagian B : Perakuan Penyelia / Penyelaras Program calon yang mengikuti pengajian secara KERJA KURSUS & TESIS / TESIS SAHAJA

(Part B: Approval from supervisor/program coordinator for student registered by course work and thesis/thesis only)Permohonan : Disokong / Tidak disokong*

Ulasan : ____________________________________

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Tandatangan : _________________ Tarikh : ___________

Nama : ______________________________________

Bahagian C : Perakuan Ketua Jabatan/Pengerusi Pusat Pengajian(Part C: Approval from Head of Department/Chair of School)

Permohonan : Disokong / Tidak disokong*

Tandatangan : _________________ Tarikh : ___________

Nama : ______________________________________

Bahagian D : Kelulusan Dekan/Pengarah Fakulti/Institut(Part D: Approval from Dean of Faculty/Director of Institute)

Permohonan : Diluluskan / Tidak diluluskan*

Tandatangan : _________________ Tarikh : ___________

Nama : ______________________________________

[*Potong yang tidak berkenaan]