UNIVERSITI KEBANGSAAN MALAYSIA

Transcription

1 UNIVERSITI KEBANGSAAN MALAYSIA A NATIONAL UNIVERSITY WITH INTERNATIONAL REACH Lekatkan gambar ukuran pasport di sini Please attach Passport-size photograph here BORANG PERMOHONAN MENGIKUTI PROGRAM PENGAJIAN SISWAZAH APPLICATION FORM FOR POSTGRADUATE STUDIES PROGRAMME (SEMESTER/SEMESTER SESI/SESSION Terima kasih kerana memilih Universiti Kebangsaan Malaysia sebagai institut pengajian siswazah anda. Thank you for choosing Universiti Kebangsaan Malaysia for your graduate study. ARAHAN KEPADA PEMOHON(INSTRUCTIONS TO CANDIDATE) 1. Sila isi borang ini dalam dua (2) salinan dan dilekatkan gambar di tiap-tiap salinan. Please fill in this application form in duplicate, and attach a photograph on each copy. 2. Pastikan semua dokumen yang diminta disertakan bersama-sama borang permohonan ini. Sila semak senarai semakan sebelum menghantar borang permohonan ini. Ensure that all documents needed are sent together with the application form. Please go over the check-list before you send in this application form. NAMA (NAME) : NO. KAD PENGENALAN/NO. PASPORT (I/C NO/PASSPORT NO.) : A. BUTIRAN PROGRAM (PROGRAMME DETAILS) [Sila tandakan mana yang berkaitan Please tick where applicable] 1. Jenis Program (Type of Programme) 2. Status Pendaftaran (Registration Status) Doktor Falsafah (PhD) Sarjana (Masters) Sepenuh masa (Full-time) Separuh masa (Part-time) Tanpa Ijazah (Non-graduate) Diploma/Diploma Siswazah (Diploma/Post Graduate Diploma) 3. Jenis Pengajian (Type of Study) Kerja kursus (Course work) Penyelidikan dan Tesis (Research and Thesis) Kerja kursus dan Tesis/Kertas projek (Course work and Thesis/Project paper) 4. Fakulti/Institut/Pusat (Faculty/Institute/Centre) Jabatan (Department) 5. Pengkhususan (Specialization)

2 B. BUTIRAN PERIBADI (PERSONAL DETAILS) 6. Nama Keluarga (Last Name) 7. Nama Anda (First Name) [Tulis dengan huruf besar dan sama seperti dalam kad pengenalan atau pasport antarabangsa bagi pemohon luar negara Write in capital letters and as in the identity card (or international passport for foreign applicants)] 8. Jantina: Perempuan Lelaki (Gender) (Female) (Male) 9. Tarikh Lahir [Hari/Bulan/Tahun] (Date of Birth [Day/Month/Year]) 10. Tempat Lahir (Place of Birth) 11. Umur (Age) tahun (year) 11. Agama (Religion) 12. Kaum (Ethnicity): Bumiputera (Bumi) Cina (Chinese) India (Indian) Lain-lain (Others): [Sila nyatakan (Please state)] 13. No. Kad Pengenalan (Identity Card No.) [Untuk warganegara Malaysia sahaja (for Malaysian citizens only)] lama (old) baru (new) 14. No. Pasport (Passport No.) [Untuk pemohon warganegara asing (for foreign applicant)] (NOTA NOTE: Sila sertakan 2 salinan pasport bersama borang permohonan ini Please attach 2 photocopies of your passport with this application) 15. Kewarganegaraan (Nationality) 16. Taraf Perkahwinan: Bujang Berkahwin (Marital Status) (Single) (Married) 17. Nama Isteri/Suami (Name of Spouse) 18. Alamat Isteri/Suami (Address of Spouse) 19. No. Telefon No. Faks (Fax No.) E-mel ( ) 20. Nama dan Alamat saudara/waris yang perlu dihubungi jika berlaku kecemasan (Name and Address of person to be contacted in case of an emergency)

3 21. No. Telefon 22. Kecacatan Anggota Badan (Physical Disabilities) 23. Alamat Tetap (Permanent Address) 24. No. Telefon 25. No. Faks (Fax No.) 26. Telefon Mobil 27. ( ) (Mobile Phone) 28. Alamat surat menyurat (Correspondence address) C. BUTIRAN PEKERJAAN/PENGALAMAN (EMPLOYMENT/EXPERIENCE) 29. Jawatan Sekarang (Present Position) 30. Nama dan Alamat Majikan Sekarang (Name and Address of Present Employer) 31. Jawatan Dahulu (Pengalaman Kerja Selepas Ijazah Pertama, jika ada) (Previous Positions [Work Experience After First Degree, if any]) Nama Jawatan Name of Positions Nama Majikan (Employer[s]) Dari-Hingga (From -To) Tempoh Bekerja (Length of Service)

4 D. KELAYAKAN AKADEMIK DAN PROFESIONAL (ACADEMIC AND PROFESSIONAL QUALIFICATIONS ) 32. Kelayakan Akademik (Academic Qualifications) Sila beri maklumat penuh mengenai ijazah/diploma yang diperolehi (Please provide full details of degrees/diplomas obtained) Nama & Alamat Institusi (Name & Address of Institution) Tahun Pengajian (Years Attended) Diploma/ Ijazah di perolehi (Degree/Diploma Obtained) [Sila lampirkan salinan sah sijil-sijil, diploma, ijazah berkenaan dan transkrip] [Please attach certified copies of all certificates, diplomas, degree received and your academic transcripts] 33. Kelayakan Profesional (Professional Qualifications) Kelulusan (Qualifications) Tahun Dianugerah (Year Awarded) Dianugerahkan oleh (Awarded by) [Sila lampirkan salinan sah sijil/surat berkenaan (Please attach certified copies of documents)] E. PENERBITAN PROFESIONAL (PROFESSIONAL PUBLICATIONS) 34. Penerbitan Profesional (Professional Publications) Tajuk Buku/Jurnal (Title of Book/Journal) Tahun Diterbit (Year of Publication) Nama dan Tempat Penerbitan (Name and Location of the Publication)

5 [Sila lampirkan senarai penuh jika perlu (Please attach a complete list if necessary)] F. PENGALAMAN PENYELIDIKAN (RESEARCH EXPERIENCE) 35. Tajuk Penyelidikan Ijazah Pertama [Sarjana Muda] (Title of Undergraduate Research [Bachelors]) 36. Tajuk Penyelidikan Ijazah Sarjana (Masters Degree Research) Tesis Disertasi Projek Penyelidikan (Thesis) (Dissertation) (Research Project) [Sila tandakan dalam petak berkenaan Please tick in the appropriate box] 37. Lain-lain Penyelidikan: (Other Research) Tajuk projek penyelidikan (Research project title) [Sila sertakan abstrak tesis/penyelidikan berkenaan Please attach the abstract of the thesis/research] G. KEMAHIRAN BAHASA MELAYU/BAHASA INGGERIS/BAHASA ARAB DAN KELAYAKAN SETARAF (MALAY LANGUAGE/ENGLISH LANGUAGE/ARABIC LANGUAGE PROFICIENCY AND EQUIVALENT QUALIFICATIONS) Bahasa (Language) Nama Peperiksaan/Ujian (Name of Examination/Test) Gred (Grade) Tahun Lulus (Year Passed) Bahasa Melayu (Malay Language) Bahasa Inggeris (English Language) Bahasa Arab (Arabic Language)

6 H. BIDANG PENYELIDIKAN YANG DIMINATI (FIELD OF RESEARCH INTEREST) a) Namakan bidang pengajian atau penyelidikan yang anda minati/pilih (State the field of study or research in which you are interested/have chosen) b) Nama tajuk penyelidikan. [Sila lampirkan usulan tesis/projek penyelidikan bersama-sama permohonan ini] (Name of research. [Please attach thesis proposal/ research project proposal with this application]) c) Namakan tempat untuk menjalankan penyelidikan jika luar dari universiti ini. (Please state place of research if other then at this university) I. BANTUAN KEWANGAN (FINANCIAL SUPPORT) Sila nyatakan sumber bantuan kewangan and (Please indicate your source of financial support) Saya dibiayai penuh oleh majikan/kerajaan negara saya (sertakan dokumen berkenaan) (I am fully sponsored by my employer/home government [attach documentation]) Saya seorang pelajar persendirian dibiayai oleh saya sendiri/keluarga saya* (I am a private student supported by myself / my family)* [Sila tandakan dalam petak berkenaan (Please tick in the appropriate box)] Nama dan alamat penaja atau organisasi yang akan membayar yuran anda (Name and address of person or organization paying your fees) [* Sila kemukakan borang Penjamin Kewangan PPS 004. Please submit the Financial Guarantor form PPS 004]

7 J. PENYOKONG (REFEREES) Namakan dua (2) orang penyokong (sekurang-kurangnya seorang ahli akademik) yang tidak mempunyai pertalian saudara dengan anda. (Name two (2) referees [at least one should be an academic referee], neither of them should be a family member or relative). Nama (Name) Jawatan (Position) Alamat (Address) PENYOKONG (REFEREE) I PENYOKONG (REFEREE) II No. Telefon No. Faks (Fax No.) E-mel ( ) K. PERAKUAN PEMOHON (DECLARATION BY APPLICANT) Saya akui bahawa segala maklumat, dan dokumen yang saya berikan adalah benar dan lengkap. Saya akui bahawa Universiti Kebangsaan Malaysia berhak menolak permohonan saya sekiranya maklumat serta dokumen didapati tidak benar dan tidak lengkap. (I declare that all information and documents provided are true and complete. I acknowledge that Universiti Kebangsaan Malaysia may reject my application if the information and documents provided are found to be untrue or incomplete. Tarikh (Date).. Tandatangan (Signature) BORANG PERMOHONAN INI BERSERTA DENGAN DOKUMEN-DOKUMEN SOKONGAN HENDAKLAH DIHANTAR TERUS KEPADA: (THIS FORM, TOGETHER WITH SUPPORTING DOCUMENTS SHOULD BE SENT TO:) DEKAN (DEAN) PUSAT PENGAJIAN SISWAZAH (CENTRE FOR GRADUATE STUDIES) UNIVERSITI KEBANGSAAN MALAYSIA UKM BANGI, SELANGOR MALAYSIA