MASTER DEGREE PROGRAMME IN USM

Transcription

1 The CPS-USM SCHOLARSHIP PROGRAMME 2012/2013 Recent Photograph (3 Photos) MASTER DEGREE PROGRAMME IN USM APPLICATION FOR ADMISSION (in duplicate) Area of Specialization: (2 sets of applications need to be reached Colombo Plan Secretariat before 9 May 2012) Institution: University Science of Malaysia USM, Penang Malaysia 1. PERSONAL INFORMATION Full Name as given in the passport (Underline the surname / last name): Date of Birth / / (dd/mm/yy) Passport Number: Date of Expiry: Home Address: Place of Birth No. of Children Sex Male/ Female* Nationality: Religion: Tel. Number: Marital Status Single/ Married 2. PRESENT EMPLOYMENT Designation/ Job Title Office Address Date of appointment to the present position / / Telephone Number Address Name & Designation of Employer/ Organisation Fax Number Employer s/ Organisation s Address Fax/ Telephone Number 1

2 3. EMPLOYMENT RECORD (please show most recent posts first) Title of Post held Present Post Dates of Service Name and Address of Employer Type of Organisation Job title and brief description of your duties Previous Post Previous Post 4. EDUCATIONAL RECORD (Must attached the Copies of Academic Transcripts) Educational Location Years Attended Degrees, Diplomas Institution From To and Certificates received Subjects or Special fields of study 2

3 5. PUBLICATIONS / RESEARCH EXPERIENCE Please list your publications or research experience, if any. 6. ADMISSION ESSAY On a separate sheet of paper, write an essay that outlines your personal and career goals, your desire to do graduate studies and commitment to attend the yearlong intensive MA programme. It should also indicate your reasons for applying for this course. This essay should be typewritten and should not be more than one page. 7. ENGLISH LANGUAGE PROFICIENCY (Copies of TOEFL or IELTS is a must) Test Date Taken Score / Grade TOEFL IELTS Other (Please specify) (Please attach a copy of the certificate). (b) Mother tongue: 8. REFEREES First Referee Second Referee Name : Name : Post : Post : Address : Address : 3

4 9. NAME AND ADDRESS OF A RELATIVE OR FRIEND IN MALAYSIA (IF ANY) Name Address : : Telephone : 10. NAME AND ADDRESS OF PERSON TO BE NOTIFIED IN AN EMERGENCY Name : Address : Telephone: I hereby, apply for admission to the USM/ Colombo Plan Master of Social Science programme. If admitted I agree to abide by its rules and regulations. I certify that to the best of my knowledge the statements made by me above are true and correct. Date: Signature Recommendations from Nominating Agency Seal of Nominating Agency (Signature of certifying government officer) Name: Designation: Agency: 4

5 To: GOVERNMENT OF MALAYSIA AND THE COLOMBO PLAN SECRETARIAT Dear Sir LETTER OF INDEMNITY In consideration of your allowing me to do my training with the relevant Government departments/ statutory boards/ institutions in Malaysia, I Passport Number of hereby declare that I shall be personally liable for and shall indemnify the Government of Malaysia and the Colombo Plan Secretariat against all liabilities, claims, losses, demands, actions, suits, proceedings, costs or expenses whatsoever arising under any statute or at common law which may be made or taken against the Government of Malaysia and the Colombo Plan Secretariat or incurred or become payable by the Government of Malaysia and the Colombo Plan Secretariat in respect of any medical illness, personal injury (whether fatal or otherwise) to or the death of any person on in respect of any injury or damage whatsoever to any property, real or personal arising out of or in the course of or by reason of my carelessness or negligence, omission or default during my training with the relevant Government departments/ statutory boards/ institutions in Malaysia. Dated this day of 2012 Signed by (Signature of trainee) (Name of trainee) in the presence of (Signature of witness) (Name & designation of witness) 5

6 CPS - USM SCHOLARSHIP PROGRAMME 2012/2013 MASTER DEGREE PROGRAMME RECOMMENDATION FOR APPLICANT Name of the Applicant: Date: The above applicant has applied for admission to the mentioned programme, and has given your name as a reference. We would appreciate your evaluation of the applicant s personal and academic qualities. In particular, we are interested in knowing, whether in your judgement, the applicant is sufficiently prepared to pursue graduate work in the field of Social Sciences. The following checklist is intended to facilitate your assessment. You may, if you prefer, attach a separate letter. Personal Traits Excellent Very good Good Average Below Average Intellectual ability Analytical ability Motivation and diligence Originality and initiative Judgement Ability in written expression Ability in oral expression Emotional stability Integrity Considering this applicant with his/her peers, how would you rate this applicant? Top 5% - Top 10% Top 25% Top 50% Lower 50% Please evaluate the applicant s general intellectual ability. Signature: Name: Position : Thank you for your cooperation. Please seal this recommendation in an envelope, sign across the flap and return it to the applicant. The applicant has been instructed to submit this recommendation together with his/her application. 6

7 MEDICAL CERTIFICATE MEDICAL REPORT TO APPLY FOR COLOMBO PLAN LONG-TERM SCHOLARSHIP PROGRAMME Post Graduate Course Applied: 1. Name of Applicant : 2. Age : Family History : Personal History: Details of important illness, accident or operation should be given together with subsequent treatment particular should be made concerning any form of tuberculosis, rheumatic fever, cholera, fever, dyspepsia, epilepsy, diabetes, nervous or mental illness and known allergies. 5. Present Condition: a. Height :... d. Vaccination :... b. Weight :... e. Tuberculin test result :... c. Physique :... f. Blood group : Respiratory System: a. Nose :... d. Pharynx :... b. Chest Expansion :... e. Lungs (R & L) :... c. Complete X - ray :... Report of the chest :... Film No.:... Hospital:... Date: Circulatory System: a. Pulse :... b. Blood Pressure :... c. Heart : Alimentary System: a. Appetite :... f. Digestion :... b. Bowels :... g. Teeth :... c. Tongue :... h. Spleen :... d. Liver :... i. Rupture :... e. Haemorrhoids : Nervous System: a. Temperament :... c. Reflexes :... b. Hearing :... d. Sight :... 7

8 10. Reproductive System: a. Varicose :... c. Syphilis :... b. Gonorrhoea : Urinary System: a. Specific Gravity :... d. Deposits :... b. Sugar :... e. Miscellaneous :... c. Albumin : Is the candidate at present: a. Undergoing a treatment : b. Receiving medical attention : c. Requiring medical attention : If so please give details I certify that the above candidate is medically fit to undertake a course in Malaysia. Signature of Physician Name Address : Date: : : 13. Certification from Nominating Agency: I certify that the candidate has been medically examined by a qualified and registered medical practitioner. Signature : Name : Rank/ Title : Agency : Seal of Nominating Agency: Note: In completing this form, particular attention should be paid to the following points: a. X-ray of chest to rule out any tuberculosis or chronic pulmonary disease. b. Kidneys no evidence of renal lesion should be present. c. Eyesight Severe errors of refraction should not be passed as these would give rise to difficulties in the training. d. Hearing deafness would possibly be considered a disqualifying factor. 8