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PLMI/LM/B18/Pin01/Mac2021

BORANG KESEDIAAN MENERIMA PELAJAR LATIHAN MENGAJAR UPSI


(ACCEPTANCE FORM FOR STUDENT TO CONDUCT PRACTICUM UPSI)

DATE of LM : ______________________ TO ______________________

1. MAKLUMAT SEKOLAH/INSTITUSI / SCHOOL/INSTITUTION INFORMATION

Nama Sekolah/Institusi /
: ______________________________________________________________________
Name of School/Institution
Alamat / Address : ______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Nombor Telefon / Phone Number : ______________________________________________________________________

E-mel / E-mail : ______________________________________________________________________

Maklum Balas Penempatan [Tandakan (√) pada petak yang berkenaan]


Placement Feedback (Tick (√) where relevant]

Menerima / Accept Menolak / Reject

2. MAKLUMAT PELAJAR (diisi oleh pelajar) / STUDENT INFORMATION (completed by student)

Nama / Name : ______________________________________________________________________

No. Matriks / Matrix No. : ______________________________________________________________________

No. Kad Pengenalan / ID No. : ______________________________________________________________________

Program / Programme : ______________________________________________________________________

Fakulti / Faculty : ______________________________________________________________________


Kod Kursus / Course Code : AT_______________
*LM / Praktikum (Practicum) / Internship Kaunseling (Internship Counselling)

SESI / SESSION : LM (16 minggu) / LM (16 weeks) : Praktikum 1 (8 minggu) / Practicum 1 (8 weeks)
* bulatkan yang berkenaan /
: LM (12 minggu) / LM (12 weeks) : Praktikum 2 (8 minggu) / Practicum 2 (8 weeks)
circle where relevant
: LM 1 (8 minggu) / LM1 (8 weeks) : Internship Kaunseling (16 minggu) /
: LM 2 (8 minggu) / LM 2 (8 weeks) Internship Counselling (16 weeks)

3. PENGESAHAN PIHAK INSTITUSI / INSTITUTION CONFIRMATION

Tandatangan Pengetua / Pengarah / Guru Besar


Cop Rasmi / Official Stamp:
Signature of Principal / Director / Headmaster

….................................................................................
Nama / Name :

Tarikh / Date :

Catatan : Borang yang telah lengkap diisi hendaklah dikembalikan kepada Pusat Latihan Mengajar & Industri melalui Penyelaras
Latihan Mengajar yang berkenaan.
Note : Completed form must be returned to Centre for Teaching Practice & Industrial Training through the relevant coordinator.

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