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PS.06/07/2010 APPLICATION FORM UTHM SCHOLARSHIP FOR POSTGRADUATE STUDENTS Recent Passport Sized Photograph SEMESTER SESSION CANDIDATE INFORMATION Name BLOK LETTER Permanent Address House Telephone No Mobile No Correspondence Address Date of Birth Day/Month/Year / Email Age Years Month Nationality Gender Religion I/C No / Passport No Marital status Single Married Programme Ph. D/Master s RESEARCH INFORMATION Specialisation Topic of Research Please enclose a complete research proposal not exceed than 300 words Faculty Date of Registration Matric No Supervisor Name Name and Code of Programme Duration of Studies The Latest Examination Results if appropriate Institution/University Scholarship/Loan Scheme Start Year ACADEMIC INFORMATION End Year Achievement or Qualification and CGPA if appropriate PREVIOUS SCHOLARSHIP OR LOAN INFORMATION Types of From Date To Date Total Activities CO-CURRICULUM ACTIVITIES INFORMATION Name of Activities Position e. g treasury secretary Designation WORKING EXPRIENCES INFORMATION Employer and Address Salary/month From Please listed your publication and research Level e. g International Local To BESTOWAL Academic achievement or award received CANDIDATE DECLARATION I certify that the information given in this application form is correct. I agree to the condition that the University has the right to reject this application to withdraw the offer of admission or to terminate my study if any information given is found to be incorrect. Date Candidate Signature APPROVAL OF APPLICATION The approval of application must made by SUPERVISOR New Project This project has done by Research Assistants but failed I BLOCK LETTER. approve that all information given above is correct and support/not support this application* Supervisor Signature Official Stamp. D/Master s RESEARCH INFORMATION Specialisation Topic of Research Please enclose a complete research proposal not exceed than 300 words Faculty Date of Registration Matric No Supervisor Name Name and Code of Programme Duration of Studies The Latest Examination Results if appropriate Institution/University Scholarship/Loan Scheme Start Year ACADEMIC INFORMATION End Year Achievement or Qualification and CGPA if appropriate PREVIOUS SCHOLARSHIP OR LOAN INFORMATION Types of From Date To Date Total Activities CO-CURRICULUM ACTIVITIES INFORMATION Name of Activities Position e. g treasury secretary Designation WORKING EXPRIENCES INFORMATION Employer and Address Salary/month From Please listed your publication and research Level e. g treasury secretary Designation WORKING EXPRIENCES INFORMATION Employer and Address Salary/month From Please listed your publication and research Level e. g International Local To BESTOWAL Academic achievement or award received CANDIDATE DECLARATION I certify that the information given in this application form is correct. g International Local To BESTOWAL Academic achievement or award received CANDIDATE DECLARATION I certify that the information given in this application form is correct. I agree to the condition that the University has the right to reject this application to withdraw the offer of admission or to terminate my study if any information given is found to be incorrect.

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