LI Placement Form B 2014/2015

UNIVERSITI MALAYSIA SARAWAK

94300 KOTA SAMARAHAN
SARAWAK

FACULTY OF ENGINEERING
Industrial Training Placement Form
To be completed by the company (Once completed please send it by post and fax it to +6082 583410)
Name of
Organization
Contact Person
Name

Area/State:

Nature of Business
Address
Contact

Office Tel

Application Status

Accepted

Fax

e-mail

Decline

Reason if decline:
List of Expected
Task(s) for the
student
Signature /
Company
Stamp

Date

Student Details (To be completed by student)

Name of
MOHD KHAMIZAN BIN RAJAN
Matric No. 34956
Student
UNIVERSITI MALAYSIA SARAWAK 94300 KOTA SAMARAHAN SARAWAK
Current
Address
Home
Address
Programme:

NO.61, KG MOYAN LAUT 94600 ASAJAYA SARAWAK

KEJURUTERAAN ELEKTRONIK (KOMPUTER)

I/C No.:

930527135309

Mobile No.

Home

e-mail

014-8814632

014-8905767

qhamillionaire15@yahoo.com

Contact

LI Placement Form B 2014/2015

To be completed by the Industrial Training Coordinator

Comments:

Approved by

Date

Signature