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):

Muka (Page) 1/4

): No.): Poskod (Post code): Alamat e-mel (E-mail address): V 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. telefon (Telephone no.II 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.Ed *Ph. faks (Fax no.D Muka (Page) 2/4 .

Please tick the relevant financial support. Provide the name of potential advisor / supervisor if already identified. objectives and outline of research. objektif dan gariskasar penyelidikan. Biasiswa (Scholarship) Pinjaman bank (Bank loan) Pembiayaan sendiri (Self-financed) – Salinan penyata akaun bank yang disahkan/Surat jaminan pembiayaan. sila berikan maklumat berikut: If you have previously been admitted to Universiti Pendidikan Sultan Idris or other universities/institutions for postgraduate programme.D programme and Master Mode A.(iii) Mod C (Mode C) X Bidang pengajian: Field of study: Fakulti: Faculty: Berikan nama bakal penasihat / penyelia jika telah dikenalpasti. please attach your research proposal to include title.D dan Sarjana Mod A sila lampirkan cadangan penyelidikan yang merangkumi tajuk. Lampirkan sesalinan dokumen. Enclose a photocopy of the document(s). (Certified photocopy of statement of bank account/ Letter of financial guarantee). Semester kemasukan yang dipilih (sila tandakan): Preferred semester for enrolment (please tick): Februari (February) Tahun (Year): Julai (July) * Nota (Note): Bagi program Ph. 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. VI BANTUAN KEWANGAN (FINANCIAL SUPPORT) Sila tandakan bantuan kewangan yang relevan. 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 Muka (Page) 3/4 . For Ph.

Processing fee RM50. UNTUK KEGUNAAN PEJABAT FOR OFFICE USE BAHAGIAN B PART B Borang Permohonan – dua salinan. Incomplete forms and/or documents will not be processed. If the information is found untrue. Borang dan/atau dokumen yang tidak lengkap. Certified examination transcript(s) – two copies. Jika ia didapati tidak benar. Please tick [/]). 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. Bhd. UPSI berhak menolak permohonan/menarik balik tawaran kemasukan. b. Untuk pemohon warganegara Malaysia (For Malaysian applicants): 1 Borang permohonan yang telah dilengkapkan – dua salinan. Certified examination/degree certificate(s) – two copies. payable to the UPSI Holdings Sdn. yang disahkan – dua salinan. 2 Salinan sijil/ijazah/ijazah-ijazah yang disahkan – dua salinan.VIII PENGAKUAN (CERTIFICATION) Saya mengaku bahawa butir-butir yang diberikan dalam permohonan ini adalah benar. Sila Salinan transkrip/transkrip-transkrip peperiksaan yang disahkan – dua salinan. melalui Wang Kiriman Pos/Wang Pos Malaysia. 5 Yuran proses RM50. Salinan ijazah/ijazah-ijazah yang disahkan – dua salinan. I certify that the information given in this application is true. tandakan [/] (Please enclose the following items in order to expedite the process. Certified photocopy of Identity Card – two copies. 4 Salinan surat tawaran biasiswa/pembiayaan (jika ada) atau slip gaji pemohon/penjaga. Applications received after the closing date will only be considered for the following semester. Salinan Kad Pengenalan – dua salinan. Permohonan yang diterima selepas dari tarikh tutup permohonan hanya akan dipertimbangkan untuk semester berikutnya. Yuran Proses Dokumen pembiayaan: Kad akuan penerimaan (K-01) Disemak oleh: Tarikh: Muka (Page) 4/4 . Certified photocopy of letter of scholarship/sponsorship award (if any) or pay slip of applicant/guardian – two copies. Completed application form – two copies. in the form of Money/Postal Order. tidak akan diproses. Salinan transkrip/transkrip-transkrip yang disahkan – dua salinan. dibayar atas nama UPSI Holdings Sdn Bhd. NOTA (NOTE): a. 3 Salinan Kad Pengenalan yang disahkan – dua salinan. UPSI has the right to reject the application/withdraw the offer of admission.