SASMEC-DEAR(G)-F001 VER: 01 REV: 03 EFFECTIVE DATE: 01 MARCH 2023
SULTAN AHMAD SHAH MEDICAL CENTRE @IIUM FORM FOR BOOKING OF CLINICAL EXAMINATION CENTRE
Sultan Ahmad Shah Medical Centre @IIUM, Jalan Sultan Ahmad Shah, Bandar Indera Mahkota, 25200 Kuantan, Pahang Darul Makmur.
Tel: 09-591 2500
PROGRAM INFO Program Title
Date of Program From To
Time From To
Rationale/Objective No. of Participant
CEC 1 CEC 3
CEC 2 CEC 4
Requested By
Contact No Email:
Institution/Faculty/
Department Facilities Request
*Please attach additional request if necessary
Please attached (if applicable):
1) Request Letter 2) Proposal
TERMS AND CONDITIONS AND DECLARATION TERMS AND CONDITION
1. Applications from students must be attached with programme approval from the university authorities.
2. Facilities must be returned in good condition. Applicants are liable for any loss or damage caused.
3. To ensure the cleanliness of the venue and its compound at all time.
4. Banner/bunting that are to be hung must get prior approval from the Public Relation Department, SASMEC
@IIUM.
5. All works shall conform to the current Health and Safety regulations and Statutory Requirements.
6. To be fully responsible for any actions, proceedings, costs, expenses, claims request made by SASMEC @IIUM in relation to the usage of the said premises.
7. The SASMEC @IIUM will not be responsible for any loss of income or any damages to the equipment of the applicants.
8. The SASMEC @IIUM/University has the right to add, modify, or change the terms and conditions stated above from time to time
By signing below, I/We hereby declare that the information given above are true and complete. I/We further confirm that I/ We have read the Terms & Conditions overleaf and agree to be bound by them. I/We agree to accept responsibility and liability for any failure in adhering to any parts of the terms and conditions and agree to compensate the SASMEC @IIUM for any loss and damage to the SASMEC @IIUM properties.
Requested By:
__________________________________
Name (with Official Stamp) Date:
SASMEC-DEAR(G)-F001 VER: 01 REV: 03 EFFECTIVE DATE: 01 MARCH 2023
SULTAN AHMAD SHAH MEDICAL CENTRE @IIUM FORM FOR BOOKING OF CLINICAL EXAMINATION CENTRE
Sultan Ahmad Shah Medical Centre @IIUM, Jalan Sultan Ahmad Shah, Bandar Indera Mahkota, 25200 Kuantan, Pahang Darul Makmur.
Tel: 09-591 2500
Any inquiries, kindly contact Department of Education and Research personnel as below:
1) Sr. Nur Nadia Mohd Zakaria
Tel: 09 09-591 2622/nadiazakaria@iium.com 2) Sr. Nor Ilani Lokman
Tel: 09-591 2554/ilani@iium.edu.my
FOR OFFICE USE ONLY Recommended by:
___________________________
Officer
Department of Education and Research SASMEC @IIUM
Date:
