HEA/TD/2013

1. Nama/Name: ______________________________________________ 2. No. Matrik/Matric no.: _________________

2. Program/Programme: ______________________________________ 4. No.Telefon/Contact no.:_______________

5. No. Kad Pengenalan/ID. no.: _______________________________ 6. Sesi / Session : _________________________

7. Kursus yang dipohon / Course Requested(s):

Kod Kursus /

Course Code Kursus / Course Name

Jam Kredit /

Credit Hour (s)

Kump. /

Group

*Status /

Status

Pengesahan Pensyarah:

Tandatangan dan Cop /

Signature and Seal

Jumlah Jam Kredit /Total Credit Hours

*Nota/Note:

R: for Repair, U: for Audit

8. Jumlah Jam Kredit Yang Didaftarkan (sebelum permohonan) /

Total credits registered (before application):

9. Jumlah Jam Kredit Yang Digugurkan / Total credits hour(s) withdrew (TD):

10. Jumlah Jam Kredit Untuk Semester Ini (Selepas permohonan) /

Total credits for the semester (after application):

Perakuan pemohon dan pengesahan / Applicant Certification and Dean endorsement :

Saya mengaku bahawa maklumat yang dinyatakan di atas adalah benar. Saya faham bahawa sekiranya

maklumat yang disampaikan adalah tidak benar, saya akan dihadapkan ke Jawatankuasa Kecurangan

Akademik

I hereby certify that all the information given above is true. I understand that I will be referred to the Academic

Disciplinary Committee if the information given is false.

______________________________ _________________________________

Tandatangan Pelajar/ Tandatangan & Cop Dekan Pusat Pengajian /

Student signature Signature and Seal of Dean of School

Tarikh/Date:____________________ Tarikh/Date:____________________

UNTUK KEGUNAAN PEJABAT (U-Assist) / FOR OFFICE USE (U-Assist)

i. Tarikh terima permohonan / date of received an application: _________________________________________

ii. Disemak dan direkod oleh / Reviewed and recorded by:______________________________________________

iii. Status permohonan / Application status : _____________________________________________________________

UNIT PENGKULIAHAN

BORANG PERMOHOHAN TARIK DIRI (TD) KURSUS

APPLICATION FORM TO WITHDRAW (TD) THE COURSE