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KEMENTERIAN PENGAJIAN TINGGI MALAYSIA

(Ministry of Higher Education Malaysia)


Bahagian Biasiswa
Aras 2, No. 2, Menara 2,
Jalan P5/6, Presint 5,
Kompleks Kerajaan Persekutuan
62200 PUTRAJAYA

INDUSTRIAL PHD FORM


APPLICANT INFORMATION
Name
NRIC No.

XXX
(new)

000000-00-0000

Date Of Birth
(ddmmyyyy)

00/00/0000

Address

XXX

Postcode

00000

State

XXX

Phone No.

000-0000 0000

E-mail

XXX

Marital Status

Married

Passport Photo

Are you a citizen of Malaysia?

Single
YES

Others

If others, specify

NO

EDUCATION INFORMATION
University/College

XXX

Study Field

XXX

University/College

XXX

Study Field

Year
Qualification

XXX
Year

Qualification

Year
Qualification

XXX

CGP
A

0.00

CGP
A

0.00

CGP
A

0.00

0000

XXX

University/College
Study Field

0000

0000

INDUSTRIAL PHD PROGRAM INFORMATION


University

UNIVERSITI XXX

Address

XXX

Postcode

00000

Supervisor

State

XXX

XXX

Research Topic

XXX

Research Area

XXX

Research
Outcome

XXX

Phone No.

Date of Enrolment (ddmmyyy)

00/00/0000

Date MOU/LOC signed ( industry & university )

00/00/0000

000-0000 0000

INDUSTRY INFORMATION
Company

XXX

Address

XXX

Postcode

00000

State

XXX

Phone No.

00-0000 0000

Industry Supervisor

XXX

Designation

XXX

Department

XXX

Responsibilities

XXX

Date Joined
Industry

00/00/0000

Industry Specialization

XXX

CONFIRMATION BY INDUSTRY
(Shall be made by Manager level and above)
I hereby confirm that the above-mentioned applicant is working in this company and any information given by him/her is true
and complete.
Signature

XXX

Date

00/00/0000

Name

XXX

Official Seal

XXX

Designation

XXX

DECLARATION BY APPLICANT
I kindly attach the following documents:
1.

A copy of Research Proposal endorsed by my supervisor appointed by the university;

2.

A copy of University Offer Letter certified by Government Officer from Professional and Management Team;

3.

A copy of Identification Card certified by Government Officer from Professional and Management Team;

4.

A copy of my academic qualification (s) certified by the Government Officer from Professional and Management Team;
and

5.

A copy of MOU/LOC between the company and the university.

I hereby declare that all the information given in this form and any attached documents are true and complete. If such
information or documents are found to be untrue or incomplete, Ministry of Higher Education has a right to cancel my
sponsorship.
Signature

XXX

Date

00/00/00000

The applicant shall submit this form together with the necessary documents to the following address through the respective
university:
Kementerian Pengajian Tinggi
Bahagian Biasiswa
Aras 2, No. 2, Menara 2
Jalan P5/6, Presint 5
Kompleks Kerajaan Persekutuan
62200 PUTRAJAYA
(Attn: Industrial PhD Program)