Sila pastikan borang ini diisi dengan lengkap dan semua dokumen sokongan dalam senarai semakan pada

halaman 4
disertakan. Borang dan/atau dokumen yang tidak lengkap tidak akan diproses. (Please ensure that this form is
completed and all the relevant documents indicated in the checklist on page 4 are enclosed. Incomplete forms and/or
documents will not be processed.)
BAHAGIAN A
PART A
UNTU !I"#NGA$AN %"#H $#&%H%N
TO BE COMPLETED BY THE APPLICANT
I BUTI'(BUTI' $#'IBA!I )PERSONAL DETAILS*
Nama penuh:
Full name:
First name Middle name Last name
Bagi Warganegara Malaysia sila tulis nama mengikut K.P. (For Malasians ! please write our name according to I.".)
No. .$./$asport:
I."./Passport no.:
Tarikh lahir:(dd/mm/yyyy)
#ate of birth $dd/mm/%
Tempat lahir:
Place of birth:
Bangsa:
&ace ! $for Malasians onl%:
+antina )sila tandakan*:
'ender $please tick%:
Lelaki
Male
Perempuan
Female
e,arganegaraan:
(ationalit:
Status perkah,inan )sila tandakan*:
Marital status $please tick%:
Bujang
)ingle
Berka!in
Married
Lain"lain
*thers
Alamat surat(menyurat-
"orrespondence address:
Negara ("ountr): $oskod (Post code):
No. tele.on (+elephone no.): No. .aks (Fa, no.): Alamat e(mel (-.mail address):
Alamat tetap )sekiranya berbe/a dengan alamat surat menyurat*-
Permanent address $if different from correspondence address%:
Negara ("ountr): $oskod (Post code):
No. tele.on (+elephone no.): No. .aks (Fa, no.): Alamat e(mel $-.mail address%:
Muka (Page) 1/4
UNI0#'SITI $#N!I!IAN SU"TAN I!'IS
INSTITUT $#NGA+IAN SIS1A2AH
I()+I+/+- *F '&0#/0+- )+/#I-)
$#'&%H%NAN #&ASUAN
$0PPLI"0+I*( F*& 0#MI))I*(%
Sila lekatkan sekeping
gambar terbaru )1A+IB*
Please affi, a recent
Photograph
$"*MP/L)*&1%
PROGRAM EKSEKUTIF
(EXECUTIVE PROGRAMME)
II "ATA' B#"AANG $#N!I!IAN )EDUCATIONAL BACKGROUND*
Nama universiti/kolej
Name of university/college
Ijazah diperolehi
Degree awarded
Tahun
Year Pengkhususan
Specialisation Kemasukan
Admission
Tamat
Graduation
III $#NGA"A&AN B##'+A )WORKING EXPERIENCE*
Nama jawatan
Position held
Nama dan alamat majikan
Name and address of employer
Tarikh
Date
Daripada
From
Hingga
To
elayakan lain yang rele3an (*ther relevant 2ualifications)
I0 1A'IS T#'!#AT )NEXT-OF-KIN*
Nama ((ame): Hubungan
(&elationship):
Alamat tetap (Permanent address):
Negara ("ountr): $oskod (Post code):
No. tele.on (+elephone no.): No. .aks (Fa, no.): Alamat e(mel (-.mail address):
0 BUTI'(BUTI' $'%G'A& 4ANG !I$%H%N )DETAILS OF PROGRAMME APPLIED FOR*
$rogram sis,a/ah )sila tandakan*: M.#d $P.%
#egree programme $please tick%:
+ika $rogram Sar5ana )sila tandakan*-
IF Master Programme $please tick%:
(i) Mode & $Mode 0%
(ii) Mod B $Mode 3%
Muka (Page) 2/4
(iii) Mod ' $Mode "% (
Bidang penga5ian-
Field of stud:
6akulti-
Facult:
Berikan nama bakal penasihat / penyelia 5ika telah dikenalpasti.
Provide the name of potential advisor / supervisor if alread identified.
Semester kemasukan yang dipilih )sila tandakan*: Fe)ruari
(Fe)ruary)
*ulai
(4ul)
Preferred semester for enrolment $please tick%:
+aun (1ear):
7 Nota )Note*-
Bagi program $h.! dan Sar5ana &od A sila lampirkan 8adangan penyelidikan yang merangkumi ta5uk9
ob5ekti. dan gariskasar penyelidikan.
For Ph.# programme and Master Mode 05 please attach our research proposal to include title5 ob6ectives and
outline of research.
0I BANTUAN #1ANGAN )FINANCIAL SUPPORT*
Sila tandakan bantuan ke,angan yang rele3an. "ampirkan sesalinan dokumen.
Please tick the relevant financial support. -nclose a photocop of the document$s%.
Biasis!a ()cholarship)
Pinjaman )ank (3ank loan)
Pem)iayaan sendiri ()elf.financed) ,alinan penyata akaun )ank yang disakan/,urat
jaminan pem)iayaan.
("ertified photocop of statement of bank account/
Letter of financial guarantee%.
Lain"lain -sila nyatakan. (*thers 7please specif8):
0II #&AHI'AN BAHASA INGG#'IS )ENGLISH LANGUAGE PROFICIENCY*
Sila lengkapkan maklumat di ba,ah )di mana berkaitan* dan sertakan salinan keputusan peperiksaan tersebut-
Please complete the information below $where relevant% and provide a cop of the results:
PEPERIK!!N
!A"#NAT#$N
T!H!P PEN"!P!I!N / #RED
S%$& / G&AD
TOEFL
IELTS
P$ %warganegara $ala&sia sahaja'
SP" ("alaysians only)
(ain)lain &ang setara dengan P$
$thers e'uivalent to SP"
Nota $(ote%:
emahiran Bahasa Inggeris bagi pemohon antarabangsa : T%#6" );;<* / I#"TS )=*
-nglish Language Proficienc for international applicants ! +*-FL $99:% / I-L+) $;%
+ika anda pernah memasuki Uni3ersiti $endidikan Sultan Idris atau lain(lain uni3ersiti/institusi bagi
program sis,a/ah9 sila berikan maklumat berikut-
If ou have previousl been admitted to /niversiti Pendidikan )ultan Idris or other universities/institutions for
postgraduate programme5 please provide the following information:
Nama universiti/institusi
Name of university/institution
Tarikh %dd/mm/&&&&'
Date (dd/mm/yyyy) e*a*)se*a* *erhenti
&easons for withdrawal Kemasukan
Admission
+erhenti
*ithdrawal
Muka (Page) 3/4
0III $#NGAUAN )CERTIFICATION*
Saya mengaku baha,a butir(butir yang diberikan dalam permohonan ini adalah benar. +ika ia didapati
tidak benar9 U$SI berhak menolak permohonan/menarik balik ta,aran kemasukan.
I certif that the information given in this application is true. If the information is found untrue5 /P)I has the right
to re6ect the application/withdraw the offer of admission.
Tandatangan pemohon-
)ignature of applicant:
Tarikh:
#ate:
I> S#NA'AI S#&AAN $#&%H%N )CHECK LIST FOR APPLICANT*
Sila sertakan perkara(perkara berikut untuk memastikan permohonan dapat diproses dengan 8epat. Sila
tandakan ?/@ (Please enclose the following items in order to e,pedite the process. Please tick 7/8).
Untuk pemohon ,arganegara &alaysia (For Malasian applicants )-
1
+orang permohonan &ang telah dilengkapkan , dua salinan-
%ompleted application form + two copies,
2
alinan sijil/ijazah/ijazah)ijazah &ang disahkan , dua salinan-
%ertified e-amination/degree certificate(s) + two copies,
alinan transkrip/transkrip)transkrip peperiksaan &ang disahkan , dua salinan-
%ertified e-amination transcript(s) + two copies,
3
alinan Kad Pengenalan &ang disahkan , dua salinan-
%ertified photocopy of #dentity %ard + two copies,
4
alinan surat tawaran *iasiswa/pem*ia&aan %jika ada' atau slip gaji pemohon/penjaga. &ang disahkan , dua salinan-
%ertified photocopy of letter of scholarship/sponsorship award (if any) or pay slip of applicant/guardian + two copies,
5
/uran proses R$01. melalui 2ang Kiriman Pos/2ang Pos $ala&sia. di*a&ar atas nama 3PI Holdings dn +hd-
Processing fee &"./0 in the form of "oney/Postal $rder0 paya1le to the 2PS# 3oldings Sdn, 4hd,
N4T! %NOTE'5
a- +orang dan/atau dokumen &ang tidak lengkap. tidak akan diproses-
#ncomplete forms and/or documents will not 1e processed,
*- Permohonan &ang diterima selepas dari tarikh tutup permohonan han&a akan dipertim*angkan untuk semester *erikutn&a-
Applications received after the closing date will only 1e considered for the following semester,
Borang Permohonan dua salinan.
Salinan ijazah/ijazah-ijazah ang disah!an dua salinan.
Salinan "rans!ri#/"rans!ri#-"rans!ri# ang disah!an dua salinan.
Salinan $ad Pengenalan dua salinan.
%uran Proses
&o!umen #em'iaaan(
$ad a!uan #enerimaan ($-)*)
&isema! oleh( Tari!h(
Muka (Page) 4/4
BAHAGIAN B
PART B
UNTU #GUNAAN $#+ABAT
FOR OFFICE USE