Matric Number : CGS ______________

NOMINATION OF SUPERVISOR/SUPERVISORY COMMITTEE

PGR01

PART A TO BE COMPLETED BY STUDENT

Name : _____________________________________________________________

Programme : _____________________________________________________________

Learning Centre : _____________________________________________________________

IC/Passport Number : ____________________________ Matric Number : CGS ______________

Intake : ____________________________

Nomination for Semester : JAN MAY SEP Year ____________

Postal Address : ____________________________________________________________

____________________________________________________________

Telephone No. : ______________ Handphone No. : ________________

Email : ____________________________________________________________

Title of Research (use BLOCK LETTERS and refer to the Academic Guideline):

Attach a 3 – 5 page synopsis of the research proposal (Structure I and II only).

Not required for Structure III (MPM, MOSHRM, MQM, MFM, MIT, MMC, MSE)

I declare that the nominated supervisor(s) is NOT in any way closely related to me.
1
Matric Number : CGS ______________

_____________________
Signature of Student

Date

PART B TO BE COMPLETED BY SUPERVISOR

DETAILS OF SUPERVISOR

Name of Supervisor*:

Specialisation :

______________

Institution & Address:

_______

Telephone : (O) _______________________________ (H/P) ___________________________________

E-mail: ________________________________________________________________________________

Signature of Supervisor

Date

* For first time Supervisor, please attach CV.

2
Matric Number : CGS ______________

PART C FOR OFFICE USE ONLY

FOR PROGRAMME DIRECTOR/COORDINATOR ONLY FOR RPMU ONLY

Approved / Not approved i-Campus Updated

Endorsed by,

_____________________________
(Signature & Stamp) (Signed & Stamp)

Date : _____________________________ Date: __________________________

Remarks (if any):