BRPK 1/2007 Pindaan Feb2021

Student Records and

Convocation Division (BRPK)
Registrar’s Office
Level 3, Menara Sultan Abdul Aziz Shah (SAAS)
Universiti Teknologi MARA
40450 Shah Alam Selangor, Malaysia
Tel: +603-55443130/3131 Fax: +603-55443111
E-mail : brpk@uitm.edu.my

APPLICATION FOR COLLECTION OF SCROLL AND OFFICIAL TRANSCRIPTS

CONVOCATION SESSION : MAC 2021
A. DETAILS OF GRADUAND

SYALMIRA BIINTI MOHD NASIR

Name : .....................................................................................................................................................
980220106154 2019695606
MyKad/Passport Number : ............................................... Student Number : .........................................
EC110
Program Code : ...........................
LOT 453 KG PANTAI SABAK, 16100 PENGKALAN CHEPA,
Correspondence Address : ......................................................................................................................
KOTA BHARU, KELANTAN.
...................................................................................................................
0135217331 syalmiramohdnasir@gmail.com
Mobile Phone Number : .......................................... E-mail : ..................................................................
MAC 2021
Convocation Session : ........................................

Mode of Collection (please tick) :

Self collect at BRPK Counter

Post to correspondence address (Within Malaysia only)

Documents to be attached (please tick) :

A copy of MyKad/Passport Signature of

A copy of representative’s MyKad/Passport
A copy of Graduates Tracer Study confirmation slip
A copy of receipt for convocation fee
A copy of receipt for payment of arrears (If any)

Graduand : .............................................................. Date : ..............................................

11 August 2021

B. GRADUAND’S CONSENT (If appointing a representative)

I hereby appoint the below mentioned name as my representative to collect the scroll and official transcripts on my behalf. I
acknowledge that Universiti Teknologi MARA will not be held responsible for any claims should the document is damaged or
lost. I take full responsibility for my actions.

Signature of Graduand : .............................................................. Date : ..............................................

C. DETAILS OF REPRESENTATIVE

Name : ......................................................................................................................................................
MyKad/Passport Number : ............................................. Relationship : ................................................

Signature of Representative : ...................................................... Date : ..............................................

FOR OFFICE USE ONLY

Received by : ................................................ Processed by : .........................................................

Date : ................................................ Date : .........................................................