Escolar Documentos
Profissional Documentos
Cultura Documentos
UTM(OIA)-IB1
PHOTOGRAPH
: 21 / 09 / 1992
Age
: 20
Gender
Male
Female
Status
Married
Single / Bachelor
Race
: MELAYU
Religion
: MOSLEM
Citizenship
: INDONESIA
Passport number
: A 5082558
: ajengdwim@gmail.com
Next of kin
: TRIYANTO
Home address :BTN KEBAN AGUNG BLOK J.NO.15 RT 013 RW 03, TANJUNG ENIM POST CODE
31716 SOUTH SUMATERA-INDONESIA
B. EDUCATION
Current home University : UNIVERSITAS SRIWIJAYA (JL. RAYA PALEMBANG PRABUMULIH K M 32
INDRALAYA, OGAN ILIR, SUMATERA SELATAN 30662 INDONESIA
Phone number: +62711580169
Current result:
3.30
Academic awards obtained (please specify name of award, organizer & date receive):
______________________________________________________________________________________
______________________________________________________________________________________
UTM(OIA)-IB1
2 semesters
1 semester
Bilateral Exchange/MOU
__________________________________________________________
Yes
No
Home Institution
Sponsor
UTM(OIA)-IB1
E. LANGUAGE
Native Language
: INDONESIA
Language proficiency
: English
Proficient
Moderate
Weak
Malay
Proficient
Moderate
Weak
Others (specify)
Proficient
Moderate
Weak
_____________________________________
F. INTER-OFFICE COMMUNICATION
Please include the contact person from the home university (international affairs officer/student exchange
coordinator) who is responsible for correspondence.
Name (Mr./Miss/Mrs.) : Dr. Ir. Siti Nurmaini, M.T
Office/ Department:FACULTY OF COMPUTER SCIENCE
Position: PD 1
Fax number :
I hereby declare that the information provided in this form is true. I acknowledge 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.
Signature
Name
Important Note
Please enclose the following documents:
1) 2 current coloured photographs (passport size)
2) Recommendation letter from the home Institution
UTM(OIA)-IB1
3) If the student is sponsored, state the details of sponsorship such as the name of sponsor, duration of
sponsorship and value of sponsorship