UNIT PERUMAHAN PELAJAR

(Student Hoousing Unit)

PERMOHONAN TINGGAL SEMASA CUTI LUAR SEMESTER(SEM. VI)

(Application to Live In During Vacation)

1. Nama

___________________________________________________

(Name :)

2. No.Matrik :

______________

3. No. Bilik

(Matric No.:)

_______________

(Room No:)

4. Kolej

______________

5. Tahun Pengajian : ______________

______________

7. No.Telefon

(College:)

(Year of Study:)

6. Fakulti
(Faculty:)

_______________

(Telephone No:)

8. Tujuan

___________________________________________________

(Reason(s))

__________________________________________________________________
Bagi Program Universiti, sila isikan tempat kosong :
(For university programme, please fill in the following :)

a. Program/ Aktiviti :
_____________________________________________
(Programme/Activity:)

b. Penganjur :

________________________________________________

(Organiser:)

c. Tempat

________________________________________________

(Venue:)

d. Pegawai yang Bertanggungjawab :

_________________________________

(Officer in charge:)

e. No.Telefon:

______________________________

(Telephone No.:)

f. Tarikh
(Duration:)

: Dari ____________________ hingga __________________

(From)

9. Bilangan Hari Penginapan

(Duration of Stay:)

(to)

: Dari _______________hingga ________________

(From)

(to)

Tandatangan Pemohon

Tarikh

(Applicants Signature)

(Date)

Peringatan:
(Note:)

i. Lampirkan surat pengesahan program

(Please attach approval letter from SAAC or any related letter from Division/ Department)

ii. Sila lampirkan senarai penuh peserta

(For group application, please submit details of participants)

UNTUK KEGUNAAN PEJABAT

(FOR OFFICE USE ONLY)

Kelulusan:
(Approval:)

LULUS

TIDAK LULUS

(Approved)

(Not Approved)

_____________________________________________________________________

Tandatangan Pengetua & Cop

Tarikh

(Principals Signature &

Official Stamp)

(Date)

Note :
1. Room No.

(Room No.:)

2. Sewaan
(Rental:)

: Bilangan Hari ______ X RM ________ = RM ________

: (No. of Days)

3. Tarikh Masuk : _______________________________

(Check in Date:)