APPLICATION FORM CONFIRMATION OF REGISTRATION STATUS

(PG 12)

PART A
Name

_______________________________________________________________ Centre

_______________________________________________________________ Matric Number

______________________________Programme : ______________________
Telephone

: __________________Email : _______________________________________

Supervisor (if relevant) : ______________________________________________________________

PART B
CONFIRMATION OF REGISTRATION STATUS
I hereby to confirm that,
a)

I am STILL INTERESTED and wish TO CONTINUE my studies in

JANUARY _____

MAY _____

SEPTEMBER ______

Please state the reasons why you did not register this semester and the previous semesters:
__________________________________________________________________________________________.

b)

I am NOT INTERESTED and wish TO TERMINATE my studies.

Please state reasons: ______________________________________________________________________.

* Tick () the appropriate box.
Student Signature: _______________________

Date: __________________

PART C
FOR FACULTY ONLY
I-Campus Updated
Endorsed by,
__________________________________
(Signature & Stamp)
Date : ________________________________

Open University Malaysia, Jalan Tun Ismail, 50480 Kuala Lumpur