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UPM/BA/SAIN/BR01
INTERNATIONAL DIVISION
UNIVERSITI PUTRA MALAYSIA
Please stick
passport sized
picture here
43400 UPM Serdang, Selangor
Malaysia
Tel: 86 10 51650127
Fax: 86 1064032524
E-mail : [email protected]
Website: upm.edu.my
APPLICATION FOR STUDY IN UPM (INBOUND)
A. NAME OF PROGRAMME
: Exchange / Short Term / Internship / Visits
B. APPLICANT / PARTICIPANT PERSONAL DETAILS (COMPULSARY)
Name
(Mr./Mrs./Miss)
Date of Birth
Age
Place of Birth
Race
Gender
Male
Citizenship/
Nationality
Passport
Number
E-mail address
Marital
Status
Religion
Female
Married
Mobile
Number
[email protected]
Next of kin
Contact
number
Home address
State &
Country
Postcode
C. EDUCATION AT HOME UNIVERSITY (COMPULSARY)
Current Home
University
(name & full address)
Phone number
Fax number
E-mail address
University
web site
Faculty which applicant
will be attached to at
home university
Degree Programme
Degree Level
Current result
(CGPA)
Diploma
Bachelor
Masters
PhD
Current
semester
Expected
year of
graduation
Academic awards obtained (please specify name of award, organiser & date received):
16/12/2011
Single
UPM/BA/SAIN/BR01
D. OTHERS (CO-CURRICULUM ACTIVITIES / SPECIAL SKILLS)
Co-curriculum activities :
Special skills :
E. STUDY IN UPM (COMPULSARY)
Faculty / Institute
applied in UPM
Does this university
have MoU with UPM?
Type of exchange
(For Student Exchange
Programme only)
Yes
No
Exchange Programme (1 or 2 semester)
Short term Programme (less than 1 semester)
 Mobility 1000 (2 weeks or more)
 Short Mobility (7-13 days)
 Industrial Training (with credit)
Internship Programme (work/research attachment)
Visits (less than 7 days)
Others, please specify _______________________________________
Period of study
(in UPM)
Commencing _______________________ to __________________________
Please specify your
research project (if
relevant)
Transfer of credits
required
(Please fill in the
Academic Transcript
Form)
Yes
No
Proposed courses to be taken in UPM:
______________________________________________________________
______________________________________________________________
______________________________________________________________
16/12/2011
UPM/BA/SAIN/BR01
F. FINANCE (COMPULSARY)
How would you intend to finance your programme?
Self-sponsored
Home Institution
Sponsor
Please specify details of sponsorships (Sponsoring Body/Institution/Association):
___________________________________________________________________________________
G. LANGUAGE
Native Language
Language
proficiency
English
Proficient
Moderate
Weak
Malay
Proficient
Moderate
Weak
Others (specify)
Proficient
Moderate
Weak
______________________________________________
H. INTER-OFFICE COMMUNICATION (COMPULSARY)
Please include the contact person from the home university (international affairs officer/student exchange
coordinator) who is responsible for correspondence.
Name
(Mr. / Miss / Mrs.)
Position
Office/Department
Correspondence address
Phone number
Fax number
E-mail address
I hereby declare that the information provided in this form is true.
Signature
: ____________________________________
Name
: ____________________________________
Date: ________________________
NOTE:
* Incomplete application form will not be processed
** Please submit copy of Academic Transcript, 4 current colored photographs (passport size) and a copy of
your passport (front page only)
16/12/2011