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UTHM/PPB/600-3/10/1

Please provide all the information requested and ensure that all testimonials, certificates and other supportindocuments (must be endorsed) are submitted with this form.Sila berikan semua maklumat yang diminta dan sila pastikan semua testimoni, sijil dan semua dokumen sokongan (yadisahkan) disertakan bersama borang ini.

Choice of programme /Pilihan program

1st Choice/Pilihan Pertama : ..

2nd Choice/Pilihan Kedua : ..

I. PERSONAL PARTICULAR / BUTIRAN PERIBADI

Full Name/Nama Penuh: NRIC No./No. Kad Pengenalan:

Gender/Jantina:

Male/Lelaki

Female/PerempuanDate of Birth/Tarikh Lahir:

Marital Status/Status Perkahwinan:

Telephone No./No.Telefon:Mobile Phone :Home:

Citizenship/Kewarganegaraan:E-Mail Address/E-mel:

Postal Address/Alamat Surat-Menyurat:

Permanent Address/Alamat Tetap:

Next of Kin/Waris Terdekat: NRIC No./No. Kad Pengenalan:

Family Relation/Hubungan Keluarga:

Telephone No./No.Telefon:Mobile Phone :Home:

CONTINUING EDUCATION CENTREUNIVERSITI TUN HUSSEIN ONN MALAYSIA

86400 PARIT RAJA, BATU PAHAT,JOHOR DARUL TAZIM

TEL: 07-4537197 FAX: 07-4536996

RecentPassport

SizedPhotograph

GambarBerukuran

Passport YangTerkini

INDUSTRIAL SKILLS ENHANCEMENT PROGRAMME (INSEP) APPLICATION FORM

BORANG PERMOHONAN PROGRAM PENINGKATAN KEMAHIRAN INDUSTRI UNTUK

SISWAZAH (INSEP)

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II. ACADEMIC QUALIFICATION / KELAYAKAN AKADEMIK

School/College/UniversitySekolah/Kolej/Universiti

From-To (Year)Dari-Hingga (Tahun)

Certificate/Diploma/DegreeSijil/Diploma/Ijazah

PNGK/GradPNGK/Gred

III. EXTRA CURRICULAR / KEGIATAN LUAR

School/CollegeSekolah/Kolej

1.

2.

3.

4.

5.

After GraduationSelepas Bergraduasi

1.

2.

3.

4.

5.

Critical Disease/Penyakit Kritikal

No/Tidak

Yes/Ya

If yes, please state/Jika ya, sila nyatakan: .

Handicap/Kecacatan Fizikal

No/Tidak Yes/Ya

If yes, please state/Jika ya, sila nyatakan: .

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IV. DECLARATION / AKUAN

I confirm that all the information given in this application form is accurate, true and complete. I agree to the conditithat the university has the right to reject the application, withdraw or terminate my study if is found that I have mafalse declaration in this application form.

Saya mengaku bahawa semua maklumat yang diberikan adalah benar. Saya faham bahawa pihak universiti mempunyai ha

untuk menolak permohonan, menarik balik tawaran atau menghentikan pengajian jika didapati maklumat yang diberikaadalah tidak benar.

Signature/Tandatangan: Name/Nama: (According to your NRIC no./Berdasarkan no. kad pengenala

Date/Tarikh : .

The completed application form must be addressed to/Borang permohonan yang telah lengkap mestilah dialamatkankepada:

DIRECTOR,

CONTINUING EDUCATION CENTRE (CEC),UNIVERSITI TUN HUSSEIN ONN MALAYSIA,

86400 PARIT RAJA, BATU PAHAT,JOHOR DARUL TA'ZIM

(u.p: Department of Professional Development)