PERMOHONAN PERTUKARAN PROGRAM

PERINGKAT PENGAJIAN IJAZAH PERTAMA (Sepenuh Masa)

APPLICATION TO CHANGE PROGRAMMES

FIRST DEGREE LEVEL (Full Time)

HEA/UKRP/TP (Salinan HEA)

(Academic Affairs Copy)

No. Matrik /Matric No.:

PMK / CGPA :

A. BUTIRAN PERIBADI / PERSONAL DETAILS

Nama/Name : __________________________________________________________________________________
No.Matrik/Matric No. : ______________

Semester : _______________

Semester Terkini/Current Semester : _______________

PMK Terkini/Current CGPA : ____________

Alamat Dewan Penginapan Pelajar/Applicants Address (Students Residential Hall) : __________________________

______________________________________________________________________________________________
Program Sekarang/

Kod / :
Code

Current Programme :

Program / :
Programme

Program Yang Dipohon/Programme Applied For :

Pilihan Petama
First Choice

Kod :
Code

Program
:
Programme

Pilihan Kedua
Second Choice

Kod :
Code

Program
:
Programme

Sebab-sebab untuk bertukar / Reasons to Change Programme : __________________________________________

______________________________________________________________________________________________
______________________________________________________________________________________________

B. LATAR BELAKANG AKADEMIK / ACADEMIC BACKGROUND :

SPM/SPMV
Pangkat/Grade
Mata Pelajaran/

Subject

: _________________________
Gred /

STPM
Mata Pelajaran /

Subjects

Gred /

Grade

Grade
Bahasa Melayu/Malaysia : _______________________

Pengajian Am/
General Paper

Bahasa Inggeris/English : _______________________

Bahasa Melayu/Malaysia : _______________________

Language

Sejarah/History
Pendidikan Islam /

Islamic Studies
Matematik/

: _______________________
: _______________________

Mathematics

: ________________________

________________
________________
________________

: _________________________
: _________________________
: _________________________

Kesusasteraan Melayu/

: _______________________

Malay Literature

: _______________________

Geografi/Geography

: _______________________

Sejarah/History

: _______________________

Ekonomi/Economy

: _______________________

_________________
_________________
_________________

: ______________________
: ______________________
: ______________________

MATRIKULASI / MATRICULATION
Kursus/Program/Aliran * /

Course/Programme/Stream *

: _______________________________________________________________________

Institusi/Institution

: _______________________________________________________________________

PMK / CGPA

: _______________________________________________________________________
Semester I

Semester II

Mata Pelajaran/

Gred/

Subject

Mata Pelajaran/

Grade

Semester III
Gred/

Subject

Grade

Mata Pelajaran/

Subject

Gred/

Grade

_______________________

: __________

______________________ : ____________

_______________________ : ___________

_______________________

: __________

______________________ : ____________

_______________________ : ___________

_______________________

: __________

______________________ : ____________

_______________________ : ___________

_______________________

: __________

______________________ : ____________

_______________________ : ___________

_______________________

: __________

______________________ : ____________

_______________________ : ___________

_______________________

: __________

______________________ : ____________

_______________________ : ___________

_______________________

: __________

______________________ : ____________

_______________________ : ___________

_______________________

: __________

______________________ : ____________

_______________________ : ___________

DIPLOMA
Kursus/Program/Bidang * /

Course/Programme/Division *

: _________________________________________________________________________

Institusi / Institution

: ________________________________________________________________________

PMK / CGPA

: ________________________________________________________

Kelayakan akademik yang digunakan untuk kemasukan ke Program Ijazah Pertama UUM (STPM/Diploma/Matrikulasi/Lain-lain)* :
_________________________________________
(nyatakan)

Academic Qualification used to enroll in the UUM First Degree Programme (Diploma / Others) * :
_________________________________________
(state)

MUET

: _____________________________

C. KEPUTUSAN PEPERIKSAAN PERINGKAT PENGAJIAN IJAZAH PERTAMA /

FIRST DEGREE EXAMINATION RESULTS
Semester 1
Kursus / Course

Semester 2
Gred / Grade

Kursus / Course

Gred / Grade

1) ___________________________________

______________

1) ___________________________________

______________

2) ___________________________________

______________

2) ___________________________________

______________

3) ___________________________________

______________

3) ___________________________________

______________

4) ___________________________________

______________

4) ___________________________________

______________

5) ___________________________________

______________

5) ___________________________________

______________

6) ___________________________________

______________

6) ___________________________________

______________

7) ___________________________________

______________

7) ___________________________________

______________

Semester 3
Kursus / Course

Semester 4
Gred / Grade

Kursus / Course

Gred / Grade

1) ___________________________________

______________

1) ___________________________________

______________

2) ___________________________________

______________

2) ___________________________________

______________

3) ___________________________________

______________

3) ___________________________________

______________

4) ___________________________________

______________

4) ___________________________________

______________

5) ___________________________________

______________

5) ___________________________________

______________

6) ___________________________________

______________

6) ___________________________________

______________

7) ___________________________________

______________

7) ___________________________________

______________

PMS/GPA : _____________

PMK/CGPA : __________

PMS/GPA : _____________

Semester 5
Kursus / Course

PMK/CGPA : __________
Semester 6

Gred / Grade

Kursus / Course

Gred / Grade

1) ___________________________________

______________

1) ___________________________________

______________

2) ___________________________________

______________

2) ___________________________________

______________

3) ___________________________________

______________

3) ___________________________________

______________

4) ___________________________________

______________

4) ___________________________________

______________

5) ___________________________________

______________

5) ___________________________________

______________

6) ___________________________________

______________

6) ___________________________________

______________

7) ___________________________________

______________

7) ___________________________________

______________

PMS/GPA : _____________

PMK/CGPA : __________

PMS/GPA : _____________

PMK/CGPA : __________

D. PERAKUAN PEMOHON / APPLICANTS DECLARATION

Saya mengesahkan bahawa maklumat yang diberikan di dalam borang permohonan ini adalah benar dan
Universiti berhak menolak permohonan/menarik balik kelulusan pertukaran program jika didapati maklumat diberikan adalah tidak
benar.

I confirm that the information given in this application is true and the University has the right to reject the application/withdraw
the approval to change programmes if the information given is found to be not true.

_______________________________
Tandatangan Pemohon

Applicants Signature

___________________
Tarikh/Date

No. Telefon : __________________________

Tel. Num. : ___________________________
No. Siri Wang Kiriman : ______________________

Nilai (RM) : ____________________

Money Order No. : __________________________

Amount (RM) : _________________