no. semakan :02 - upm : pusat antarabangsa

PERKHIDMATAN UTAMA
PUTRA INTERNATIONAL (PUSAT ANTARABANGSA)
UNIVERSITI PUTRA MALAYSIA
43400 UPM Serdang, Selangor, Malaysia
Tel: 603-8946 6048 l6198 E-mail: intl@upm.edu.my
CHECKLIST FOR SPECIAL PASS APPLICATION
PLEASE USE CAPITAL LETTTRS
Name:
Passport
Expiry Date
No:
of passport:
No.
d
d
Required Documents
No
(Please arrange the document according to the sequence given.)
of
m
m
Tick
v
Checklist for Special Pass Application (SOK/PIC/SS0B)
Visa & Pass Application Form (UPM/PIC/BR0UAPPLICATION FORM)
2
v
(If Complete)
Office Use
copy lnnliernl
1
Y
HD
cs
1
1
(If you have more than 1 dependent, this form filt up once only)
TYPED Letter address to Immigration Director Malaysia, Kuala Lumpur
state the reason to apply special pass
Student study status (Registration Slip / Deferment Letter / Withdrawal
Letter / Terminate Letter)
Copy of flight ticket / new offer letter
A4 sized copy passport (all pages including the empty pages)
A4 sized copy passpoft (front page & student pass page)
A4 sized copy passport (student visit page)
IM - 55 form
Overstay form (Format A - PK(O) IM,c.04 / FQ-01)
3
4
5
6
7
B
9
10
-
2
2
1
1
1
2
2
2
Note
1.
2.
3.
4.
5.
This checklist is for ONE application. Additional of other dependent application
will require the same number of copies.
Documents which DO NOT follow the specifications are deemed incomplete and
shall be rejected
Pease DO NOT staple your documents and photo.
Use a paper clip instead.
Please number all the copies to avoid missing pages and delay at EMGS /
immigration.
Checked by
Date
HD
CS
SEMAKAN
ISU
NO.
NO.
TARIKH KUATKUASA
I Helpdesk
I Counter Staff
:02
:02
t
04107 /20L6
1 drp.
1
v
OPERAS! PERKHI DMATAN SOKONGAN
ruq!E-rlFFt
ulG{t&l
PUTRA INTERNATIONAL (BAHAGIAN ANTARABANGSA)
Kod Dokumen: UPM/BA/BR01/Application
li[,,'ffi]i:[!yi*]:l
VISA & PASS APPLICATION FORM
TYPE OF APPTICATION
NEW
RENEWAL
STUDENT/STAFF
STUDENT/STAFF
INVITATION TETTER
SPECIAL PASS
RETEASE LETTER
VDR
NEW DEPENDENT
STUDENT,S
/
RENEWAL DEPENDENT
TRANSFER
CANCELLATION
STICKER
SHORTENING
/
STAFF'S PARTICULARS:
1. NAME
2. MATRTC NO.
/
STAFF NO.
3. PROGRMME
(for student only)
f--l
Bachetor
EMaster l-l
pr'o
4. FIELD OF STUDY
s. FACULTY
/
INSTITUTE
DATEoFBTRTH
7. NATIONALITY
,f]
E
E
(DD/MM/YYYY)
8. TELEPHONE NO
E-MAIL
9. PASSPORT NO
EXPIRY DATE
10. PASS EXPIRY DATE
EtrE
.E trE
(DD/MM/YYYY)
(DD/MM/YYYY)
11. NEAREST
MALAYSIA
EMBASSY
:
(For VDR opplicotion)
NO. SEMAKAN
NO,
ISU
TARIKH KUAT KUASA
00
01
:-t,sl2oL5
1 drp. 2
I certify that all information given in this application is true and I have also submitted application for me or my dependents:
student/working pass/visit pass (New/ Renewal/ Special Pass/ Shorten/ Endorsement)
Student/ Applicant's Signature
FOR OFFICE USE ONLY
PAYMENT'S CHECKLIST: ( Note: Pleose present the original receipt from the Bursar Counter ond the copy of the Receipt upon
submission of your opplication to the Counter of Visa & Poss.)
INVITATTON TETTER
RELEASE LETTER
CLAIM TETTER
TOTAr AMOUNT (RM)
:
Officer's Signature and Stamp
SEMAKAN :
lSU
:
TARIKH KUAT KUASA :
NO.
NO.
Date
00
01
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TORMAT A
FORMAT TINGGAL LEBIH MASA
HADIR DI PE]A3AT
Nama
(Name)
,lantina
:
(Gender):.................
No.Pasport(PassportNo.):..
Majikan
r-
*
(Employer)
.-..-Warganegara(Nationality):..........,......
.,...,.....Pekerjaan(Profession):...............
;.............................,.-lenls Pas (Type of Passes):...
.-L
Sebab-sebab tinggal lebih mase(Kemukakan dokumen sebagai buki):
(
Reason for oversta yi n g, plea se enclose proof)
:
Tandatangan (Signature)
Tarikh(Date):
UNTUK KEGUf'IA,AN PEIABAT (FOR OFFICE USE OltLy)
PERAKUAN PEGAWAI:
Tandatangan
Cop Nama & Jawatan Pegawai
Tarikh:
KEPUTUSAH
n
t:]
Ada sebab munasabah telah tinggal lebih masa
Keluarkan Pas Khas dan Lanjutkan pas
Keluarkan Memo Periksa Keiuar
[]
Tidak ada sebab munasabah telah tinggal lebih masa rujuk Bahagian penguatkuasa
[]
Tandalangan
Cop Nama & Jawatan Pegawai
Tarikh
:
TORMAT A
FORMAT TINGGAL LEBIH MASA
HADIR DI PE]A3AT
Nama
(Name)
,lantina
:
(Gender):.................
No.Pasport(PassportNo.):..
Majikan
r-
l
*
(Employer)
.-L
crrll-rui ldirdL
r
.-...Warganegara(Nationality):..........,......
.,...,.....Pekerjaan(Profession):...............
;..,..........................,.-lenls Pas (Type of Passes):...
d5\Irpriy u.11t Ut r-i551._..._......
Sebab-sebab tinggal lebih masa(Kemukakan dokumen sebagai bukti):
(
Reason for oversta yi n g, plea se enclose proof)
:
Tandatangan (Signature)
Tarlkh(Date):
UNTUK KEGUf'rA,AN PEIABAT (FOR OFFICE USE
OilLy)
PERAKUAN PEGAWAI:
Tandatangan
Cop l{ama & lawatan Pegawai
Tarikh:
KTPUT[
n
t:]
SAT'I
Ada sebab munasabah telah tinggal lebih masa
Keluarkan Pas Khas dan Lanjutkan pas
Keluarkan Memo Periksa Keiuar
[]
Tidak ada sebab munasabah telah tinggal lebih masa rujuk Bahagian penguarkuasa
[]
Tandalangan
Cop Nama & Jawatan Pegawai
Tarikh
: