CENTRE FOR UNIVERSITY-INDUSTRY COLLABORATION (CUIC)

UNIVERSITI UTARA MALAYSIA

ORGANISATION NOMINATION FORM

PRACTICUM SESSION: A_____
--------------------------------------------------------------------------------------------------------------------Students Name

: ___________________

Matric Number

: ______________

Programme

: ___________________

Current CGPA

: ______________

DPP Address

: ___________________

Majoring (if any) : ______________

Mobile Number

: ___________________

Email Address

: ______________

Organisations Name
Address

Business Type
Tel. Number
Fax Number
Officers In-charge
Email Address

Date: _______________

Students Signature: _____________

Note:
1. CUIC reserves the right to nominate students at any relevant organization.
2. Kindly submit this form to CUIC during add/drop week next semester.
3. Kindly Contact CUIC at +6049285193/5194 for more information.