UNISEL-BC00-F001

INDUSTRIAL TRAINING PROGRAMME

STUDENT PERSONAL DETAILS
PART A: STUDENT INFORMATION

NAME:
MATRIC NO: NRIC/PASSPORT:
DATE OF BIRTH: PLACE OF BIRTH:
FACULTY:
PROGRAMME:
MAJORING FIELD: *if any
LATEST CGPA: TOTAL CREDIT HOUR:
DURATION OF INDUSTRIAL TRAINING: to:
INDUSTRIAL TRAINING SEMESTER:
EMAIL :

CORRESPONDENCE
ADDRESS:

PHONE NO: (HOUSE): - (MOBILE):

HOME ADDRESS:
-
(if different from
correspondence address)

PHONE NO: (HOUSE): - (MOBILE): -

PART B: STUDENT SIGNATURE

I hereby certify the above information is true

…………………………………
(mohd shahrizan bin mohmad sha)
Date: 14 april 2020
PART C: ACCEPTANCE
Supported by: Date: Sign:
Industrial Training Coordinator
Received by: Date: Sign:
Business, Research, Industrial
Linkages & Consultancy (BRIC)
Revised: 20214

________________________________________________________________________________________________
Centre for Business, Research, Industrial Linkages & Consultancy (BRIC)
Universiti Selangor, Ground Floor, Block Z, Jalan Zirkon A7/A, Seksyen 7
40000 Shah Alam, Selangor Darul Ehsan.
T: 03-5522 3511
E: bric@unisel.edu.my