A.      APPLICATION DETAILS
  Programme of Study (*) :  
  Mode of Study (*) :  
  Academic Year (*) :  
Intake (*) :    
  For Research Programmes Only:
Area of Specialization :
Proposed Research Title :
Proposed Supervisor :

  B.       PERSONAL DETAILS
Full Name (*) :  
Gender (*) :   NRIC / Passport No (*) :


eg: 756233025415

Date of Birth (*) :  

    dd/mm/yyyy

Place Of Birth(*) :
Age (*) :   Marital Status (*) :
Nationality (*) :   Ethnicity :     Religion (*) :
Mailing Address (*) :  
   
   
Postcode (*) :   City (*): State / Province (*) : Country (*) :
Tel No (*) :   Mobile No :   Email (*) :  

 
Please provide valid email

   
Permanent Address @ Home Country (if different from Mailing address) :  
   
   
Postcode : City : State / Province: Country :  

 

  C.       QUALIFICATIONS
  Please provide details of degree obtained from University / College / Other Tertiary Institutions
 Academic Qualification Obtained (*)
Result / Achievement (CGPA or equivalent) (*)
Name of Institution (*)
Period of study (*)
Language of Instruction(*)
From (mm/yyyy)
To (mm/yyyy)
 
 
 
 
 
 
 
 
   
Other Professional Qualifications :  
   
   
Research Experience:  
   
Publication (provide citations):  
   

  D.       LANGUAGE PROFICIENCY
  Proficiency in Malay language (For local applicants only)
Proficiency in Malay language in SPM/MCE
Grade
Year Passed
  Proficiency in English language (For all applicants)
Test
Date Taken (dd/mm/yyyy)
Grade/Point Obtained
  1.  
 
  2.  
 
  3.  
 
  4.  
 

  E.       WORKING EXPERIENCE
  Please provide details of current and previous employment (start with the most recent)
Present Position :   Since :
  (dd/mm/yyyy)
Business Address :  
   
   
Postcode :   Country :      
Tel No :   Fax No :   Email :  
From (dd/mm/yyyy)
To (dd/mm/yyyy)
Position and Nature of Work
Employer
       
 
 
       
 
 
       
 
 
       
 
 
       
 
 
       
 
 

  F.       FINANCIAL SUPPORT
  Please indicate your source of financial support while studying in UTP (*)


I am a self-financed student/have financial support from my family
I am fully sponsored by my home government/empoyer/other organization (attach evidence)
I am awarded a scholarship by (attach evidence)
I am applying for UTP Graduate Assistantship Scheme (GA) -Research and Full-time only. If it is unsuccessful, I wish to study as a full-fee student

I am applying for the Schlumberger Prestigious Scholarship. If it is unsuccessful, I wish to study as a full-fee student


  G.       REFEREES
  Please provide details of two referees who are able to comment on your academic capabilities.
Name (*)
Organization (*)
Tel. No. (*)
Email Address
  1.
  2.

  H.       PERSON TO BE NOTIFIED IN CASE OF EMERGENCY
 
Name (*):   Relationship (*):  
Address (*):  
   
   
Postcode :   City : State / Province :
Country (*):
  
Tel No (*):          
Fax No :
   Email :  

  I.       DECLARATION
I hereby declare that I have personally filled in this Application Form and that the information contained herein is complete and accurate to the best of my knowledge. I understand that withholding or giving false information will make me ineligible for admission and future enrollment. I further understand that if at any time the information or part thereof stated in this declaration is found contrary to facts, the University has the authority to disqualify, or if I am already admitted, to terminate my candidature.
Signature of Applicant
Date

Note: (*) is required field.




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