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UTM.07.08.10/24.

10/MPMUTM/JPPI/SMT/FORM ( )

REGISTRATION FORM
STUDENT MEDIA TEAM Your Picture

PART A

Name : ……………………………………………………………………….

I/C Number : ……………………………………

Phone (h/p) : ……………………….

Phone (Home) : ……………………….

Email : …………………………………….

Religious : …………………………………….

Race : …………………………………….
PART B

College : …………………………………………………………………………

Block : ………….

Room : ………….

Home Address : …………………………………………………………………………

…………………………………………………………………………
PART C

Matrix : …………………………………………………………………………

Year : ………….

Course : ………….

Semester : ………….

Faculty : …………………………………………………………………………

PART D
Experiences :

YEAR LEVEL
BASIC AVERAGE ADVANCE
1. Web Researcher/Developer
2. News Editor
3. News Writer

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4. Multimedia Designer
5. Videographer
6. Photographer

PART E
Tendency to become as

Web Researcher/Developer

News Editor

News Writer

Multimedia Designer

Videographer

Photographer

PART F

Involvement in associations, clubs, JKM:


1. _______________________________as__________________________ (
)
2. _______________________________as__________________________ (
)
3. _______________________________as__________________________ (
)
4. _______________________________as__________________________ (
)
5. _______________________________as__________________________ (
)

PART G

I hereby declare that all the information above are true. If the information provided is
fault, this application will be rejected immediately.

Signature

____________________________

Name : ............................................................

I/C : …………………………………………………

Date : …………………………………………………

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