Form B

UNIVERSITI UTARA MALAYSIA Recent

Photograph

A) PERSONAL INFORMATION

Name (as in Identity Card/Passport): ____________________________________________________________________

Matric No.: ________________________ Identity Card/Passport No. : ________________________

Date of Birth: ______________________ Place of Birth: ___________________________________

Gender*: Male  Female 

Religion: ________________ Race: ________________ Nationality: _______________________

Marital Status (single/ married/ widow): ______________________

Permanent Address: Mailing Address:

__________________________________________ _________________________________________

__________________________________________ _________________________________________

Postal Code: _______________________________ Postal Code: ______________________________

State: _____________Country: __________________ State: _____________Country: __________________

Tel: _______________________________________ E-mail: ___________________________________

B) PROGRAMME DETAILS

Programme (as stated in the offer letter): ________________________________________________________________

Place of Study (as stated in the offer letter): ______________________________________________________________

Mode of Studies:* Full-time  Part-time 

Financial Support* Private  Loan  Scholarship/Sponsored 

Name & Address of Sponsor: _____________________________________________________________________

_____________________________________________________________________
C) HIGHER ACADEMIC QUALIFICATION

Name & Address of Institution Diploma/Degree Obtained Year Awarded

D) EMPLOYMENT DETAIL/ EXPERIENCE

Present Occupation: ________________________________________________________________________________

Sector (public/private/personal): ________________________________________________________________________

Experience: ________________ Year ________________ Month

Monthly Income: RM _________________ __________________ / USD _______________________________________

E) FAMILY BACKGROUND

Name of Spouse: ___________________________________________________________________________________

No. of Dependents: _________________________________ person(s)

Mailing Address: ___________________________________________________________________________________

___________________________________________________________________________________

Postal Code: ______________________ Tel. No.: ________________________________

In case of emergency, person to be notified: _________________________________________________________

Relationship: ___________________________________________________________________________________

Address: ___________________________________________________________________________________

___________________________________________________________________________________

Postal Code: ______________________ Tel. No. : ___________________________

______________________________ ______________________________
(Student’s Signature) (Date)

*Note: Please tick (x) whichever applicable