Application Form SS19

Applicant's Particulars

Name *

Date of Birth *

Home Address *

Home Address

City

State/Province

Zip/Postal

Country

Gender *

Male

Female

Citizenship *

Passport Number *

Mobile Number *

Email Address *

Next of Kin *

Next of Kin's Contact Number *

Educational Background

Name of Home University *

Website/URL of Home University *

Name of Home Faculty *

Name of Program at Home University (Bachelor/Masters/PhD) *

e.g. Bachelor of Mechanical Engineering

Program Particulars

Checkboxes

SS19 Environmental Ecoexplorer Summer School (E2S2)

Date of Session *

Session 1 (8 - 22 August 2020)

Attachment

A Copy of your Passport *

Maximum file size: 5.12MB

Declaration

Declaration *

I hereby declare that the information provided in this form is true. I acknowlegde that Universiti Teknologi Malaysia reserves the right to vary or reserve any decision regarding admission or enrolment made on the basis of the given information.