UTM.07.08.10/24.

10/MPMUTM/JPPI/SMT/FORM ( )

REGISTRATION FORM
STUDENT MEDIA TEAM Your Picture

PART A
Name : ……………………………………………………………………….
I/C Number : ……………………………………
Phone (h/p) : ……………………….
Phone (Home) : ……………………….
Email : …………………………………….
Religious : …………………………………….
Race : …………………………………….
PART B
College : …………………………………………………………………………
Block : ………….
Room : ………….
Home Address : …………………………………………………………………………
…………………………………………………………………………
PART C
Matrix : …………………………………………………………………………
Year : ………….
Course : ………….
Semester : ………….
Faculty : …………………………………………………………………………

PART D
Experiences :

YEAR LEVEL
BASIC AVERAGE ADVANCE
1. Web Researcher/Developer
2. News Editor
3. News Writer
4. Multimedia Designer
5. Videographer
6. Photographer

PART E
Tendency to become as

Web Researcher/Developer

News Editor

News Writer

Multimedia Designer

Videographer

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 Photographer

PART F

Involvement in associations, clubs, JKM:

1. _______________________________as__________________________ ( )
2. _______________________________as__________________________ ( )
3. _______________________________as__________________________ ( )
4. _______________________________as__________________________ ( )
5. _______________________________as__________________________ ( )

PART G

I hereby declare that all the information above are true. If the information provided is fault,
this application will be rejected immediately.

Signature

____________________________

Name : ............................................................

I/C : …………………………………………………

Date : …………………………………………………

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