SHUKRI YAJID FELLOWSHIP

Application Form
Please ensure that this form is completed and all the relevant documents indicated in the checklist on page 3 are enclosed. Incomplete forms and/or documents will not be processed.

PERSONAL PARTICULARS
Full Name (according to Passport / IC): Passport No. / NRIC

Correspondence Address: (All correspondence from the Admission & Record Dept will be mailed to this address)

Postcode: Town/City: Permanent Address: (If different from above)

State:

Country:

Please affix most recent passport-sized photo here (compulsory)

Postcode: Mobile Phone No.:

Town/City: Office/House Phone No.:

State: Marital Status:

Country: E-mail Address:

Date of Birth:

_____/______/_____
Day Month Year

Race (for Malaysian):

Citizenship:

Religion:

Sex:

Place of Birth:

DETAILS OF PROGRAM
Level of program (please choose): Program Structure: a) With thesis Field of study: b) Without thesis Program name: School/institute: Provide the name of potential advisor / supervisor if already identified: Masters PhD

When do you intend to enroll in the above program?

March

May

Nov

Year:

Note: please attach your research proposal (type-written, approximately 300 words) to include title, problem identification, objectives, methodology, significant contribution to new knowledge and proposed schedule of work.

EDUCATIONAL BACKGROUND
List all colleges or universities that you have attended. Name of colleges / universities
(include city and state) Admission

Year
Graduation

Degree Awarded

CGPA

Specialization

If you have previously been admitted to MSU or other universities/institutions for postgraduate programs, please provide the following information: Name university / institution Dates
Admission Withdrawal

Reasons for withdrawal

ENGLISH LANGUAGE PROFICIENCY

Examination TOEFL IELTS Other equivalent qualifications: _____________________
(please indicate)

Score / Grade

Note: Score / Grade must be minimum 550 for TOEFL or Band 6 for IELTS.

WORKING EXPERIENCE
List all employers that you have served till now. Name of Employer
(include address)

Dates of service
From Month / Year To Month / Year Position held

Last Drawn Monthly Salary (RM)

/ / /

/ / /

MEDICAL RECORD
Please indicate if you are currently receiving medical treatment for any health related condition: Type of health related condition:

CONTACT PERSON IN CASE OF EMERGENCY

Name: Address: Relationship: Phone No.:

CERTIFICATION BY APPLICANT
I certify that the information provided in connection with this application is true and correct. I agree that MSU reserves the right to vary or reverse any decision regarding the admission made on the basis of incomplete or false information. I also agree to abide by all MSU rules and regulations.

_____________________________
(Applicants signature)

___________________________
(Date)

CHECKLIST FOR APPLICANTS

Please enclose the following items in order to expedite the process: Completed Application Form. Report from 2 (two) referees (Attachment) sealed envelope. 2 certified copies of first and/or master degree certificate(s) for PhD candidates. 2 certified copies of first degree certificate for Master candidates. 2 certified copies of all examination transcripts. 2 certified copies of TOEFL / IELTS result(s). 2 copies of research proposal for program with thesis. 3 certified copies of passport (all pages) passport must be valid for minimum of ONE year at the time of application. 5 copies of passport-sized photograph. A bank draft of USD 25 as processing fee, payable to MSU HOLDINGS SDN BHD

FOR OFFICE USE ONLY

This application is: Remark : approved conditionally approved unsuccessful

_____________________________ (Signature of Registrar)