B/BA02/0619/V4

BORANG PERMOHONAN
JABATANPENANGGUHAN PENGAJIAN/CUTI
PENGURUSAN AKADEMIK & KUALITIKHAS
APPLICATION FORM FOR DEFERMENT OF STUDY/SPECIAL
BANGUNAN CANSELORI LEAVE
KOLEJ UNIVERSITI TATI
SesiTELUK KALONG
Semester 24000 KEMAMAN, TERENGGANU
Sessi
TEL : 09-8601012,
Semester     on 1052,
    1053,
    1054,
/   1055,
  1058
 
FAKS : 09-8601050
E-mail : jpak@tatiuc.edu.my
BAHAGIAN A: MAKLUMAT PEMOHON
SECTION A : DETAILS OF APPLICANT

NAMA:
Name                                                        
NO KAD NO
MATRIK: TELEFON:
Matric No.                 Tel. No.   -              
PROGRAM :
Program                                              
ALAMAT :
Address                                                      
                                             
Masalah Masalah
ALASAN Masalah peribadi kewangan
PENANGGUHAN: kesihatan Personal Financial
Reasons for deferment   Health problem   problem   problem
Lain-lain (sila
nyatakan)
Others (please
  state)                              
PENANGGUHAN  
SEMESTER
Semester of deferment:     /     /  

 
    /     /  
    /     /        
 
( Tandatangan) ( Tarikh Permohonan )
Signature Date of application

BAHAGIAN B: PENGESAHAN PENGERUSI PROGRAM

SECTION B: HEAD OF PROGRAM’S VERIFICATION

Ulasan (jika
ada):
Comment (if
any)                                                  

                                                 

1
 B/BA02/0619/V4

    /     /        
                           

( Tandatangan ) ( Cop Rasmi ) ( Tarikh )

Signature Official Stamp Date

BAHAGIAN C: PERAKUAN DEKAN

SECTION C : DEAN’S RECOMMENDATION
Ulasan:
Comment                                                      

                                                     

    /     /        
                           
( Tandatangan ) ( Cop Rasmi ) ( Tarikh )
Signature Official Stamp Date

BAHAGIAN D: SEMAKAN JABATAN PENGURUSAN AKADEMIK & KUALITI

SECTION D: CHECKED BY DEPARTMENT OF ACADEMIC & QUALITY MANAGEMENT
Ulasan:
Comment                                                      

                                                     

    /     /        
                           
( Tandatangan ) ( Cop Rasmi ) ( Tarikh )
Signature Official Stamp Date

BAHAGIAN E: KELULUSAN TIMBALAN REKTOR (AKADEMIK DAN PENGANTARABANGSAAN)

SECTION E: DEPUTY RECTOR (ACADEMIC & INTERNATIONALIZATION)’S APPROVAL
Tidak
Status Berjaya Berjaya
Permohonan: Success Not
Application status   ful   successful

    /     /        
                           
( Tandatangan ) ( Cop Rasmi ) ( Tarikh )

2
 B/BA02/0619/V4

Signature Official Stamp Date

Aliran : Pemohon Pengerusi Program Dekan JPAK TR (A&P) JPAK Pendaftar &Pemohon
Flow Applicant H.O.P Dean JPAK Deputy Rector JPAK Registrar & Applicant