11/28/2018 https://online.uitm.edu.my/ipsis/print.

cfm

INSTITUTE OF GRADUATE STUDIES

POSTGRADUATE
APPLICATION FORM

Full Name : WAN FAKHARUDDIN BIN WAN AHMAD KHOHAR

New IC No / Army / Police /
Passport No
: 951129136069
Programme : EC706 - MASTER OF SCIENCE IN HIGHWAY ENGINEERING
Campus : B - UITM SHAH ALAM

SECTION A - INFORMATION OF APPLICATION

Session of Admission : 20192 - March 2019
Qualification : DEGREE HOLDER Type of Study : COURSEWORK
Programme Level : MASTERS Mode of Study : FULL TIME

SECTION B - PARTICULARS OF APPLICANT

Full Name : WAN FAKHARUDDIN BIN WAN AHMAD KHOHAR
New IC No / Army / Police /
: 951129136069 UiTM Staff Number : -
Passport No
Email : fakharuddinkhohar@gmail.com Date of Birth : 29/11/1995
State of Birth : SARAWAK Country of Birth : MALAYSIA
Gender : MALE Citizenship : MALAYSIAN
Race : MALAY Religion : ISLAM
Maritial Status : SINGLE Disability Type : NOT APPLICABLE
Mailing Address : NO.7 , LORONG PADANG PERMAI 42 , PERUMAHAN PADANG
: Postcode : 25200
City : KUANTAN State : PAHANG
Country : MALAYSIA
Tel. Number : Mobile Number : 0179336216

SECTION C - WORKING EXPERIENCE

Designation : Number of Years : NO WORKING EXPERIENCE
Discipline :
Name of Employer :
Address of Employer :
: Postcode :
City : State :
Country : Office Phone Number :

SECTION D - PARENT / GUARDIAN INFORMATION

FATHER (AS IN BIRTH CERIFICATE)
Name : WAN AHMAD KHOHAR BIN WAN OSMAN
Race : MALAY Citizenship : MALAYSIAN
MOTHER (AS IN BIRTH CERIFICATE)
Name : FAUZIAH BINTI BOLHASSAN
Race : MALAY Citizenship : MALAYSIAN
GUARDIAN (IF APPLICABLE)
Name :
Race : Citizenship :

INSTITUTE OF GRADUATE STUDIES

POSTGRADUATE

https://online.uitm.edu.my/ipsis/print.cfm 1/2
11/28/2018 https://online.uitm.edu.my/ipsis/print.cfm
APPLICATION FORM

SECTION E - HIGHEST ACADEMIC QUALIFICATION

Name of University : UNIVERSITI TEKNOLOGI MARA (UITM)
: UNIVERSITI TEKNOLOGI MARA
Qualification : BACHELOR DEGREE Student ID : 2016217856
Year of Admission : 2016 Year of Graduation : 2019
Reason of Quit : COMPLETED STUDIES
Field of Study : CIVIL ENGINEEERING
CGPA : 3.01 Class : 2ND CLASS

SECTION F - TOEFL / IELTS FOR INTERNATIONAL APPLICANT

Result : Score :

SECTION G - RESEARCH EXPERIENCE (IF APPLICABLE) - FOR PROGRAMME BY RESEARCH

Research Title :
Research Grant : Duration of Research : YEARS

SECTION H - REFEREE 1 (ACADEMIC)

Name : HJ. IR BASIR BIN NORDIN
Address : FACULTY OF CIVIL ENGINEERING UNIVERSTITI TEKNOLOG
: SHAH ALAM SELANGOR 40450 MALAYSIA Postcode : 40450
City : SHAH ALAM State : SELANGOR
Country : MALAYSIA
Telephone Number : 60 17-624 5414

SECTION I - REFEREE 2
Name of Employer : ZANARIAH ABD RAHMAN
Address of Employer : FACULTY OF CIVIL ENGINEERING UNIVERSTITI TEKNOLOG
: SHAH ALAM SELANGOR 40450 MALAYSIA Postcode : 40450
City : SHAH ALAM State : SELANGOR
Country : MALAYSIA
Telephone Number : 0 12-757 1074

SECTION J - RECOMMENDED SUPERVISOR (IF APPLICABLE) - FOR PROGRAMME BY RESEARCH

Name of Supervisor :
Faculty :
:
Telephone Number : Email :

https://online.uitm.edu.my/ipsis/print.cfm 2/2