PROGRAM EKSEKUTIF

(EXECUTIVE PROGRAMME)

Sila lekatkan sekeping gambar terbaru (WAJIB) Please affix a recent Photograph (COMPULSORY)

UNIVERSITI PENDIDIKAN SULTAN IDRIS INSTITUT PENGAJIAN SISWAZAH

INSTITUTE OF GRADUATE STUDIES

PERMOHONAN KEMASUKAN (APPLICATION FOR ADMISSION)

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 I UNTUK DILENGKAPKAN OLEH PEMOHON TO BE COMPLETED BY THE APPLICANT

BUTIR-BUTIR PERIBADI (PERSONAL DETAILS)

Nama penuh: Full name: First name No. K.P./Pasport: I.C./Passport no.: Tempat lahir: Place of birth: Jantina (sila tandakan): Gender (please tick): Lelaki Male Middle name Last name
Bagi Warganegara Malaysia sila tulis nama mengikut K.P. (For Malaysians please write your name according to I.C. )

Tarikh lahir:(dd/mm/yyyy) Date of birth (dd/mm/yyyy) Bangsa: Race (for Malaysians only): Perempuan Female Bujang Single Kewarganegaraan: Nationality: Berkahwin Married Lain-lain Others

Status perkahwinan (sila tandakan): Marital status (please tick): Alamat surat-menyurat: Correspondence address:

Negara (Country): No. telefon (Telephone no.): No. faks (Fax no.):

Poskod (Post code): Alamat e-mel (E-mail address):

Alamat tetap (sekiranya berbeza dengan alamat surat menyurat): Permanent address (if different from correspondence address):

Negara (Country): No. telefon (Telephone no.): No. faks (Fax no.):

Poskod (Post code): Alamat e-mel (E-mail address):

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LATAR BELAKANG PENDIDIKAN (EDUCATIONAL BACKGROUND) Nama universiti/kolej Name of university/college Ijazah diperolehi Degree awarded Kemasukan Admission Tahun Year Tamat Graduation Pengkhususan Specialisation

III

PENGALAMAN BEKERJA (WORKING EXPERIENCE)

Nama jawatan Position held

Nama dan alamat majikan Name and address of employer

Tarikh Date Daripada From Hingga To

Kelayakan lain yang relevan (Other relevant qualifications)

IV

WARIS TERDEKAT (NEXT-OF-KIN)

Nama (Name): Alamat tetap (Permanent address):

Hubungan (Relationship):

Negara (Country): No. telefon (Telephone no.): No. faks (Fax no.):

Poskod (Post code): Alamat e-mel (E-mail address):

BUTIR-BUTIR PROGRAM YANG DIPOHON (DETAILS OF PROGRAMME APPLIED FOR)

Program siswazah (sila tandakan): Degree programme (please tick): Jika Program Sarjana (sila tandakan): IF Master Programme (please tick): (i) (ii) Mode A (Mode A) Mod B (Mode B)

M.Ed

*Ph.D

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Mod C (Mode C)

Bidang pengajian: Field of study: Fakulti: Faculty: Berikan nama bakal penasihat / penyelia jika telah dikenalpasti. Provide the name of potential advisor / supervisor if already identified.

Semester kemasukan yang dipilih (sila tandakan): Preferred semester for enrolment (please tick):

Februari (February) Tahun (Year):

Julai (July)

* Nota (Note):

Bagi program Ph.D dan Sarjana Mod A sila lampirkan cadangan penyelidikan yang merangkumi tajuk, objektif dan gariskasar penyelidikan. For Ph.D programme and Master Mode A, please attach your research proposal to include title, objectives and outline of research.
VI BANTUAN KEWANGAN (FINANCIAL SUPPORT)

Sila tandakan bantuan kewangan yang relevan. Lampirkan sesalinan dokumen. Please tick the relevant financial support. Enclose a photocopy of the document(s). Biasiswa (Scholarship) Pinjaman bank (Bank loan) Pembiayaan sendiri (Self-financed) Salinan penyata akaun bank yang disahkan/Surat jaminan pembiayaan. (Certified photocopy of statement of bank account/ Letter of financial guarantee).

Lain-lain [sila nyatakan] (Others [please specify]):

VII

KEMAHIRAN BAHASA INGGERIS (ENGLISH LANGUAGE PROFICIENCY)

Sila lengkapkan maklumat di bawah (di mana berkaitan) dan sertakan salinan keputusan peperiksaan tersebut: Please complete the information below (where relevant) and provide a copy of the results: PEPERIKSAAN EXAMINATION TOEFL IELTS SPM (warganegara Malaysia sahaja) SPM (Malaysians only) Lain-lain yang setara dengan SPM Others equivalent to SPM Nota (Note): Kemahiran Bahasa Inggeris bagi pemohon antarabangsa TOEFL (550) / IELTS (6) English Language Proficiency for international applicants TOEFL (550) / IELTS (6) Jika anda pernah memasuki Universiti Pendidikan Sultan Idris atau lain-lain universiti/institusi bagi program siswazah, sila berikan maklumat berikut: If you have previously been admitted to Universiti Pendidikan Sultan Idris or other universities/institutions for postgraduate programme, please provide the following information: Tarikh (dd/mm/yyyy) Nama universiti/institusi Date (dd/mm/yyyy) Sebab-sebab berhenti Name of university/institution Reasons for withdrawal Kemasukan Berhenti Admission Withdrawal TAHAP PENCAPAIAN / GRED SCORE / GRADE

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PENGAKUAN (CERTIFICATION)

Saya mengaku bahawa butir-butir yang diberikan dalam permohonan ini adalah benar. Jika ia didapati tidak benar, UPSI berhak menolak permohonan/menarik balik tawaran kemasukan. I certify that the information given in this application is true. If the information is found untrue, UPSI has the right to reject the application/withdraw the offer of admission. Tandatangan pemohon: Signature of applicant:
IX SENARAI SEMAKAN PEMOHON (CHECK LIST FOR APPLICANT)

Tarikh: Date:

Sila sertakan perkara-perkara berikut untuk memastikan permohonan dapat diproses dengan cepat. tandakan [/] (Please enclose the following items in order to expedite the process. Please tick [/]). Untuk pemohon warganegara Malaysia (For Malaysian applicants):
1 Borang permohonan yang telah dilengkapkan dua salinan. Completed application form two copies. 2 Salinan sijil/ijazah/ijazah-ijazah yang disahkan dua salinan. Certified examination/degree certificate(s) two copies. 3 Salinan Kad Pengenalan yang disahkan dua salinan. Certified photocopy of Identity Card two copies. 4 Salinan surat tawaran biasiswa/pembiayaan (jika ada) atau slip gaji pemohon/penjaga, yang disahkan dua salinan. Certified photocopy of letter of scholarship/sponsorship award (if any) or pay slip of applicant/guardian two copies. 5 Yuran proses RM50, melalui Wang Kiriman Pos/Wang Pos Malaysia, dibayar atas nama UPSI Holdings Sdn Bhd. Processing fee RM50, in the form of Money/Postal Order, payable to the UPSI Holdings Sdn. Bhd.

Sila

Salinan transkrip/transkrip-transkrip peperiksaan yang disahkan dua salinan. Certified examination transcript(s) two copies.

NOTA (NOTE): a. Borang dan/atau dokumen yang tidak lengkap, tidak akan diproses. Incomplete forms and/or documents will not be processed. b. Permohonan yang diterima selepas dari tarikh tutup permohonan hanya akan dipertimbangkan untuk semester berikutnya. Applications received after the closing date will only be considered for the following semester. UNTUK KEGUNAAN PEJABAT FOR OFFICE USE

BAHAGIAN B PART B

Borang Permohonan dua salinan. Salinan ijazah/ijazah-ijazah yang disahkan dua salinan. Salinan transkrip/transkrip-transkrip yang disahkan dua salinan. Salinan Kad Pengenalan dua salinan. Yuran Proses Dokumen pembiayaan: Kad akuan penerimaan (K-01)

Disemak oleh:

Tarikh:

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