UPSI/IPS-1/BO 07

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PERMOHONAN PENANGGUHAN PENGAJIAN/SEMESTER

APPLICATION FOR DEFERMENT OF STUDY/SEMESTER
INSTITUT PENGAJIAN SISWAZAH (IPS)/ INSTITUTE OF GRADUATE STUDIES (IGS)

BAHAGIAN A UNTUK DILENGKAPKAN OLEH PELAJAR

SECTION A TO BE COMPLETED BY THE STUDENT

Nama penuh/ Full name : ................................................................................................................................................

No. Matrik/ Matric No. :

Program/ Programme : ...

Pengkhususan /Specialization :

Fakulti/ Faculty :

Semester/ Semester :

Nyatakan semester hendak ditangguh Semester 1 Semester 2 Sesi/Session 20../ 20.

/ State the semester to be deferred : (September) (February)

Pernahkah anda menangguh Ya/ Yes Tidak/ No

pengajian sebelum ini?
Have you previously deferred your ............................................................................................................................................
study?

Jika ya, sila nyatakan bila dan berapa

lama:
If yes, state when and the duration: ................................................................................................................................................

Nyatakan sebab-sebab penangguhan

(jika sebab kesihatan, lampirkan
dokumen sokongan): ...
State the reason for deferment (if due to
............................................................................................................................................
medical reason, attach supporting
............................................................................................................................................
documents) :

Pengesahan Pelajar/ Student Verification:

Tandatangan Pelajar/ Students Signature: Tarikh/ Date
 UPSI/IPS-1/BO 07
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BAHAGIAN B UNTUK KEGUNAAN BENDAHARI DAN PERPUSTAKAAN
SECTION B FOR LIBRARIAN / BURSAR USE

1. BENDAHARI/ BURSAR 2. PERPUSTAKAAN/ LIBRARIAN

Disahkan bahawa pelajar ini tidak berhutang dengan Disahkan bahawa pelajar ini tidak meminjam buku/telah
Universiti Pendidikan Sultan Idris (UPSI). memulangkan semua buku yang dipinjam.
It is certified that this student does not owe any money to It is certified that this student has not borrowed any book/has
Sultan Idris Education University (UPSI). returned all borrowed books.

Nama & Tandatangan: Nama & Tandatangan:

Name & Signature: Name & Signature:

.
Cap Rasmi/ Official Stamp Cap Rasmi/ Official Stamp

Tarikh/ Date Tarikh/ Date

BAHAGIAN C UNTUK KEGUNAAN PENYELARAS PROGRAM /PENYELIA

SECTION C FOR PROGRAM COORDINATOR/SUPERVISOR USE

Sokongan Penyelaras Program/ Penyelia: Nama & Tandatangan:

Recommendation of Programme Coordinator/Supervisor: Name & Signature:

Diluluskan/ Approved

Cap Rasmi/ Official Stamp
Tidak Diluluskan/ Not Approved

Tarikh/ Date

BAHAGIAN D UNTUK KEGUNAAN FAKULTI & IPS

SECTION D FOR FACULTY & IGS USE

1. FAKULTI/ FACULTY 2. KEGUNAAN PEJABAT IPS /

IGS OFFICE USE
Sokongan Dekan/Timbalan Dekan:
Recommendation of Dean / Deputy Dean of Faculty:

Diluluskan/ Approved

Tidak Diluluskan/ Not Approved

Nama & Tandatangan: Nama & Tandatangan:

Name & Signature: Name & Signature:

Cap Rasmi/ Official Stamp Cap Rasmi/ Official Stamp

Tarikh/ Date Tarikh/ Date