BTK 100 KERAJAAN MALAYSIA
(GOVERNMENT OF MALAYSIA)
BORANG MAKLUMAT PERIBADI PELAJAR ANTARABANGSA (PERSONAL PARTICULARS FORM FOR INTERNATIONAL STUDENTS)
BAHAGIAN 1 – BUTIR-BUTIR DIRI (Part 1 – Personal Particulars)
1. Nama Penuh: ______________________________________________________________________________
(Full name) (Family) (First) (middle) (last)
2. Lain-lain nama, jika ada : ____________________________________________________________________
(Other name(s), if any) 3. Nama Cina (jika berkaitan) (Chinese name (if applicable))
a) Dalam tulisan Cina : ________________________________________________________________
(In Chinese characters)
b) Dalam kod perdagangan : ___________________________________________________________
(In Commercial code)
4. Tarikh Lahir : ______________________________________________________________________
(Date of birth) hari/bulan/tahun
(day) (month) (year)
5. Tempat lahir : _____________________________________________________________________
(Place of birth) Daerah/Negeri
(state) (country)
6. Kewarganegaraan : _________________________________________________________________
(Citizenship)
7. Alamat tetap : _____________________________________________________________________
(Permanent address)
____________________________________________________________________
____________________________________________________________________
8. Pekerjaan sekarang : ________________________________________________________________
(Present occupation)
9. Majikan sekarang : _________________________________________________________
(Present employer)
10. Tujuan lawatan : _________________________________________________________
(Purpose of visit)
11. Tempoh berada di Malaysia : ________________________________________________
(Duration of stay in Malaysia)
BAHAGIAN PENGURUSAN AKADEMIK JABATAN PENDAFTAR
43600, UKM, BANGI, SELANGOR
IPTA-B2 TEL: 89118463 / 8465 / 8452
12. Alamat semasa berada di Malaysia : _____________________________________________
(Address whilst in Malaysia) 13. Tarikh dan tempoh lawatan
lalu ke Malaysia (jika ada) : ___________________________________________________
(Date and duration of stay of previous visits to Malaysia if any)
BAHAGIAN II – BUTIR-BUTIR DOKUMEN PERJALANAN (Part II – Particulars of Travel Document)
1. Jenis dokumen :
(Type of Document)
____________
(a) Pasport (Passport) /____________/ b) Lain-lain (Sila nyatakan)
Others (please specify)
_____________________
_____________________
2. Nombor : ______________________________________
(Number)
3. Tarikh dan tempat dikeluarkan : _____________________________________________
(Date and place of issue)
4. Pihak berkuasa yang : ___________________________________________________
mengeluarkan (Issuance authority)
5. Tempoh sah : _________________________________________________________
(period of validity)
6. Alamat Kedutaan Malaysia / Konsulate / Pesuruhjaya Tinggi Malaysia di luar Negara yang berhampiran dengan rumah anda. (The nearest Malaysian Embassy / Consulate / High Commission in your country)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
BAHAGIAN III – BUTIR-BUTIR PENGANJUR TEMPATAN
(jika berkaitan)
(Part III - Particulars of local sponsor) (if applicable) 1. Nama dan alamat
Institusi yang menganjur : _______________________________________________________
(Name and address of
sponsoring institution) _______________________________________________________
2. Nama penganjur di Malaysia: _______________________________________________________
BAHAGIAN PENGURUSAN AKADEMIK JABATAN PENDAFTAR
43600, UKM, BANGI, SELANGOR
IPTA-B2 TEL: 89118463 / 8465 / 8452
BAHAGIAN PEGURUSAN
AKADEMIK
UKM
(Name of referee in Malaysia)
_______________________________________________________
(a) Dalam tulisan Cina (jika berkaitan) (In Chiness characters) (if applicable)
(b) Dalam kod perniagaan (jika berkaitan) (In commercial code) (if applicable)
3. Tarikh dan tempat lahir penganjur : __________________________________________
(Date and place of birth of referee)
__________________________________________
__________________________________________
4. Nombor kad pengenalan pengajur : __________________________________________
(Identity card number of referee)
5. Alamat pengajur : ____________________________________________________________
(Address of referee)
____________________________________________________________
____________________________________________________________
___________________________ ____________________________
Tarikh (Date) Tandatangan pemohon
(Signature of applicant)
