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PS.

06/07/2010

APPLICATION FORM UTHM SCHOLARSHIP FOR POSTGRADUATE STUDENTS

Recent Passport Sized Photograph

SEMESTER __________ SESSION______________

CANDIDATE INFORMATION Name (BLOK LETTER): Permanent Address: House Telephone No:

Mobile No:

Correspondence Address:

Email:

Date of Birth : (Day/Month/Year) / Gender: /

Age : ______Years Month

Nationality: ______

Religion: I/C No / Passport No: Marital status: Single Married

Programme (Ph.D/Masters)

RESEARCH INFORMATION Specialisation:

Topic of Research (Please enclose a complete research proposal not exceed than 300 words):

Faculty:

Date of Registration:

Matric No:

Supervisor Name:

Name and Code of Programme:

Duration of Studies:

The Latest Examination Results (if appropriate):

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1 ACADEMIC INFORMATION End (Year)

Institution/University

Start (Year)

Achievement or Qualification and CGPA (if appropriate)

Specialisation

Scholarship/Loan Scheme

PREVIOUS SCHOLARSHIP OR LOAN INFORMATION Types of Institution From (Date) Scholarship/Loan

To (Date)

Total

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Activities

CO-CURRICULUM ACTIVITIES INFORMATION Name of Activities Position (e.g treasury, secretary)

Level (e.g International Local)

Designation

WORKING EXPRIENCES INFORMATION Employer and Address Salary/month From

To

(Please listed your publication and research) 1. 2. 3.

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3 BESTOWAL Academic achievement or award received:

_____________________________________________________________________________________________ _____________________________________________________________________________________________

CANDIDATE DECLARATION I certify that the information given in this application form is correct. I agree to the condition that the University has the right to reject this application, to withdraw the offer of admission or to terminate my study if any information given is found to be incorrect.

_________________________ Date

_________________________ Candidate Signature

APPROVAL OF APPLICATION The approval of application must made by: SUPERVISOR New Project This project has done by ______ Research Assistants but failed I (BLOCK LETTER).. approve that all information given above is correct and support/not support this application.

_________________________ Date

_________________________ Supervisor Signature & Official Stamp

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