Matric Number : CGS ______________

NOMINATION OF SUPERVISOR/SUPERVISORY COMMITTEE

CGSR 01
PART A

TO BE COMPLETED BY STUDENT

Name

: _____________________________________________________________

Programme

: _____________________________________________________________

Learning Centre

: _____________________________________________________________

IC/Passport Number

: ____________________________ Matric Number : CGS ______________

Intake

: ____________________________

Nomination for Semester : JAN

Postal Address

MAY

SEP

Year ____________

: ____________________________________________________________
____________________________________________________________

Telephone No.

: ______________

Handphone No. : ________________

Email

: ____________________________________________________________

Title of Research (use BLOCK LETTERS):

Signature of Student

Date

Matric Number : CGS ______________

PART B

TO BE COMPLETED BY SUPERVISOR(S)

DETAILS OF SUPERVISOR 1
Name of Supervisor*:
Specialisation :

______________

Institution & Address:

Telephone : (O) _______________________________

_______
(H/P) ___________________________________

E-mail: ________________________________________________________________________________

Signature of Supervisor

Date

DETAILS OF SUPERVISOR 2 (if necessary)

Name of Supervisor*:
Specialisation :

______________

Institution & Address:

Telephone : (O) _______________________________

_______
(H/P) ___________________________________

E-mail: ________________________________________________________________________________

Signature of Supervisor

Date

DETAILS OF SUPERVISOR 3 (if necessary)

Name of Supervisor*:
Specialisation :

______________

Institution & Address:

Telephone : (O) _______________________________

_______
(H/P) ___________________________________

E-mail: ________________________________________________________________________________

Signature of Supervisor

Date

Matric Number : CGS ______________

* For first time Supervisor(s), please attach CV.

PART C

FOR OFFICE USE

FOR CGS ONLY

FOR PROGRAMME COORDINATOR ONLY

I-Campus Updated

Approved / Not approved

Endorsed by,

__________________________________
(Signature & Stamp)

(Signature & Stamp)

Date : _____________________________

Date : ________________________________