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  PUSAT PENGURUSAN PENYELIDIKAN(RMC) UTM/RMC/F/0106Pindaan: 0 POST DOCTORAL SCHEME APPLICATION FORM SECTION A (To be completed by the applicant) PERSONAL PARTICULARS Name (write in BLOCK Letters and UNDERLINE Surname/family name)Permanent address  Tel (home) Tel (office)HPE-mailMailing address Date of birthAge * Marital Status: Single/Married*Sex: Male/FemaleNationality Religion Passport no.Date Ethnic group (if applicable) Place ofIssue  ACADEMIC QUALIFICATIONS ParticularsDiplomaBachelorMasterDoctorateName of certificateClass/CGPAField Year 1 / 5 Photographof Applicant  Name andplace of institutionattended* Are you bonded with your sponsor? Yes/No (Please enclose necessary documents if any) English qualification. (Please enclose result slip)  TOEFL : IELTS :Date of test : Date of test :  WORK EXPERIENCE DurationDesignationOrganization PUBLICATIONS (journal, books, chapter in book, proceeding and other publications) Proposed date and duration of appointment.  APPLICANT’S DECLARATION I hereby proclaim that all information given as stated above is accurate and true. I understandthat any inaccurate or false information or omission of material information will render thisapplication invalid and that, if admitted and awarded Post Doctoral Fellowship on the basis ofsuch information, my candidature can be terminated and I can also be subjected to any penaltyin the agreement. 2 / 5  Name : Signature : Date : Please attach latest Curriculum Vitae, Certified copy of Masters and PhD, Result Slip of TOEFL/IELTS and photocopy if international passport. SECTION B (To be completed by the Supervisor) SUPERVISOR’S PARTICULARS Name NIRC (new) Title of position held*Status of position held: Permanent/Temporary/Contract/ Assignment/Secondment or others (please indicate)Office addressTel :Fax :E-mail : Are there any possibilities that you will retire/going for sabbatical leave/be transferred to other places/end your contract within the proposed appointment period of this applicant? RESEARCH INFORMATION  Your R&D grant title and name of awarding agency/institutionName of the Project LeaderList of project members and their respective institution 3 / 5  Date of Approval :Date of Completion :Total amount of the grant (Malaysian Ringgit) :  Type of research (please √ at the right box)Research grant numberExperimental applied researchPrioritized research Strategic researchField of researchProject Title (main research project) :Please indicate the number of students (post doctoral/master/doctorate/NSF student) currentlyunder your supervision. Provide the project proposal for Post Doctoral Fellow. SUPERVISOR’S DECLARATION I affirm that all information given is accurate and correct.Name : Signature : Date : Please attach Project Proposal and other supporting documents. SECTION C DEAN OF RESEARCH ALLIANCE SUPPORTEDNOT SUPPORTED 4 / 5


Jul 26, 2017
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