UTeM.

29/1/1

UNIVERSITI TEKNIKAL MALAYSIA MELAKA Sila lekatkan

PUSAT PENGAJIAN SISWAZAH sekeping gambar
terbaru (WAJIB)
KARUNG BERKUNCI 1752 PEJABAT POS DURIAN TUNGGAL 76109 Please affix a
DURIAN TUNGGAL MELAKA recent photograph
MALAYSIA
TELEFON: 06-233 3375 FAKS: 06-233 3369

BORANG PERMOHONAN MENGIKUTI PROGRAM PENGAJIAN SISWAZAH

APPLICATION FORM FOR POST GRADUATE STUDIES PROGRAMME
NOTA : 1. Sila taip atau tulis dengan pen mata bulat. (Please type or print boldly [preferably with a ball-point pen]).
NOTES : 2. Untuk mempercepatkan proses, sila sertakan maklumat lengkap yang menyokong permohonan.
(To expedite the application, please provide all information requested)
A. BIDANG PENGAJIAN (FIELD OF STUDY)

Program yang dipohon : Sarjana Doktor Falsafah

(Proposed Programme) Master Doctor of Philosophy

Jenis Pengajian : Kerja Kursus Penyelidikan

(Type of Study) Taught Courses Research

Bentuk Pendaftaran : Sepenuh Masa Sambilan

(Type of Registration) Full Time Part Time

I. Mod Penyelidikan (Research)

Bidang Pengajian
(Field of Study)

Fakulti
(Faculty)

Tajuk Penyelidikan
(Title of research):

Penyelia yang dicadangkan (jika berkaitan)

(Proposed Supervisor (if applicable):

Sila kepilkan cadangan penyelidikan anda bersama borang permohonan

(Please enclose your research proposal with application form)

II. Mod Kerja Kursus (Taught Courses)

Sila tanda √ (Please tick √)

Faculty of Electronic & Computer Engineering Faculty of Manufacturing Engineering

Telecommunication Systems Manufacturing Systems Quality Systems
Engineering Engineering

Computer Engineering Industrial Engineering Precision Engineering

Electronic Systems

Faculty of Information and Communication Faculty of Technology Management and Technopreneurship

Technology
Software Engineering And Technology and Innovation Management
Intelligence

Internetworking Technology Advanced Operations Management

1
B. KETERANGAN PERIBADI (PERSONAL DATA)
Nama penuh (HURUF BESAR) (Full Name [IN BLOCK LETTERS]):

Alamat surat-menyurat (Postal Address)

Alamat Tetap (jika berlainan daripada di atas) (Permanent Address [If different from above]):

Telefon (Telephone) :
Rumah (Home) : Pejabat (Office) : H/P :
No. Faks (Fax No) : Emel (E-Mail) :
Negara Tempat Lahir: Tarikh Lahir (Hari/Bulan/Tahun): Umur (Age): No. Pasport / K.P:
(Country of Birth): Date of Birth(Day/Month/Year): (Passport No. / IC No.)

Warganegara (Nationality) Jantina (Gender): Bangsa (Race): Agama (Religion):

Status Perkahwinan (Marital Status):

Nama dan alamat waris terdekat (Name and address of next of kin):

Telefon (Telephone): No.Faks (Fax No):

Adakah anda mengidap sebarang [penyakit atau ketidakupayaan], jika ada, sila nyatakan:
(Do you suffer from any form of disease [physical or other disability], if so, please specify):

C. PENCAPAIAN AKADEMIK (ACADEMIC ACHIEVEMENT)

Sila lampirkan salinan transkrip Sijil/Diploma/Ijazah yang telah disahkan
(Please attach certified copy of certificates/diplomas/degrees and transcripts)

Nama Institusi Tahun (Year) Ijazah diperolehi Kelas / CGPA

(Name of Institute) dari (from) hingga (to) (Degree awarded) (Class / CGPA)

D. PENGALAMAN KERJA (WORK EXPERIENCE)

Jawatan Tempoh Berkhidmat Nama & Alamat Majikan

(Position) (Period of Employment) (Name & Address of Employer)
dari (from) hingga (to)

2
E. KEMAHIRAN BAHASA INGGERIS (ENGLISH LANGUAGE PROFICIENCY )
Sila lengkapkan maklumat di bawah [di mana berkaitan] dan sertakan salinan keputusan peperiksaan tersebut:
(Please fill in the required information below [where relevant] and provide a copy of the results):

PEPERIKSAAN TAHAP PENCAPAIAN / GRED

(EXAMINATION) (SCORE / GRADE)

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])

F. LAIN-LAIN KELAYAKAN DAN KEAHLIAN DALAM BIDANG IKHTISAS

(OTHER QUALIFICATIONS AND PROFESSIONAL MEMBERSHIPS)
Berikan kelayakan dan keahlian ikhtisas yang berkaitan dengan permohonan ini sahaja
(Give details of all other qualification or professional qualifications relevant to this application)

G. PEMBIAYAAN PENGAJIAN (FINANCIAL SUPPORT)

Sila tandakan √ bagi pembiayaan kewangan (Please indicate √ for financial support)

a. Pembiayaan sendiri (Self financing)

b. Majikan (Employer)

c. Lain-lain (Others)

Jika [b] atau [c], sila beri nama dan alamat majikan atau agensi yang akan membiayai pengajian
(If [b] or [c] please give name and address of employer or agency that will provide the financial support)

H. PENYOKONG (REFEREES)
Beri nama dan alamat dua orang penyokong yang mengenali anda. Salah seorang daripada penyokong sebaiknya terdiri daripada
kakitangan akademik yang boleh menerangkan rekod akademik anda.
(Give names and addresses of two persons acquainted with you. One of them should be able to comment on your academic
record)
(i) (ii)
Nama:
(Name):

Alamat:
(Address):

Jawatan:
(Designation):

No. Telefon / No. Faks:

(Telephone No ./Fax No.):
3
I. PERAKUAN PEMOHON (DECLARATION)

Saya mengaku bahawa butir-butir yang diberikan dalam permohonan ini adalah benar. Jika ia didapati tidak benar,
UTeM berhak menolak permohonan / menarik balik tawaran kemasukan.

(I declare that this information given in this application is true. If any information is found to be untrue,
UTeM has the right to reject the application / withdraw the offer of admission

................................................................................... ..............................................................
Tandatangan (Signature) Tarikh (Date)

J. PANDUAN MENULIS CADANGAN PENYELIDIKAN (GUIDELINE IN WRITING RESEARCH PROPOSAL)

Sila gunakan senarai dibawah dalam menulis cadangan penyelidikan anda.

(Please include the following items in your research proposal)

i. Tajuk, latarbelakang dan permasalahan penyelidikan

(Title, background and statement of problem);

ii. Objektif, skop dan kepentingan kajian

(Objectives, scope and significance of study);

iii. Kajian literatur secara ringkas

(Brief literature review);

iv. Kaedah penyelidikan dan rekabentuk kajian

(Research methodology and research design);

v. Perancangan, pelaksanaan dan jadual kerja kajian

(Planning, execution, milestone);

vi. Rujukan
(Reference)

4
BAHAGIAN I SEMAKAN PERMOHONAN
(PART I) (CHECK LIST FOR APPLICATION )
Sila sertakan perkara-perkara berikut untuk memastikan permohonan dapat diproses dengan cepat. Sila tanda [ ]
(Please enclose the following items in order to expedite the proses. Please tick [ √ ])

Untuk pemohon warganegara Malaysia (For Malaysian applicant)

1. Borang permohonan UTeM.29/1/1 yang telah dilengkapkan

(Completed application form UTeM. 29/1/1)
2. Laporan daripada 2 orang penyokong, Borang UTeM.29/1/3 [dalam sampul surat yang dilakri dan ditandangani pada bahagian tersebut]
(Report from two referees-form UTeM.29/1/3[in sealed envelope and with the referees signatures across it])

3. Salinan kad pengenalan yang disahkan

(Certified ID card)
4. Salinan Sijil/Diploma/ijazah yang disahkan
(Certified copies/diploma/degree)
5. Salinan transkrip/transkrip-transkrip peperiksaan yang disahkan
(Certified copies of examination transkript [s])
6. Cadangan Penyelidikan
(Research Proposal)
7. Yuran Proses [RM30] melalui Wang Kiriman Pos/Wang Pos Malaysia, dibayar atas nama Bendahari UTeM
(Processing fee [RM30] in the form of Money/Postel Order, payable to the Bendahari UTeM)

8. Salinan surat tawaran pembiayaan

(Certified copy of letter of sponsorship letter [if any])
9. Kad akuan penerimaan]
(Acknowledgement)
For International Applicant:

1. Completed application form (UTeM.29/1/1)

2. Personal Particulars (UTeM.29/1/2)

3. Report from two referees (UTeM.29/1/3) in sealed envelope

4. Certified copies of examination transkript(s)

5. Certified copies of examination transkript(s)

6. Certified copies of TOEFL/IELTS result(s)

7. Research Proposal

8. Certified photocopyof passport (pages with photograph, personalparticulars and validity for at least one year)

9. Recent passport-sized photograph – (two copies)

10. RM60 (for those who reside in Malaysia) in the form of Money/Postal Order (payable to the Bendahari, UTeM)
Or (For those who apply from outside Malaysia) in the form of bank Draft (Payable to the Bendahari, UTeM)
11. Certified photocopy of financial support letter (if any) or Financial support (if any)

12. Acknowledgement card

Permohonan yang lengkap hendaklah dihantar kepada:-

(Please submit completed application form to):

Dekan Dean
Pusat Pengajian Siswazah Centre For Graduate Studies
Universiti Teknikal Malaysia Melaka Universiti Teknikal Malaysia Melaka
Karung Berkunci 1752, Pejabat Pos Durian Tunggal Locked Bag 1752, Durian Tunggal Post Office
76109 Durian Tunggal, Melaka 76109 Durian Tunggal, Melaka
MALAYSIA. MALAYSIA
*NOTA(NOTE):
Borang dan/atau dokumen yang tidak lengkap akan melambatkan proses kelulusan.
(Incomplete form and/or documents will delay the approval process)

5
1. Borang UTeM.29/1/1

2. Borang UTeM.29/1/2

3. Borang UTeM.29/1/3 daripada dua orang penyokong

6
4. Salinan ijazah/ijazah-ijazah yang disahkan

5. Salinan transkrip/transkrip-transkrip yang disahkan

6. Cadangan Penyelidikan

7. Salinan Kad Pengenalan

8. Salinan pasport (untuk pemohon antarabangsa sahaja)

9. Gambar berukuran pasport (untuk pemohon antarabangsa sahaja)- dua keping

10. Yuran proses, jumlah : ________________________________________

11. Dokumen pembiayaan : ________________________________________

12. Kad akuan penerima

BAHAGIAN II UNTUK KEGUNAAN PEJABAT

PART II (FOR OFFICE USE )

Disemak Oleh : __________________________ Tarikh : ______________________