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1 0.J i - f)(()0 ".- [ 1 1,I' STUENTS PERSONAL ATA LAMPIRAN B. \1\ R e f\ \)A (\f'\ R t\ \( C-; ~ 1 Name. Other name, if any: ~. 2 Sex: [2J M F 3 Marital Status:..?}.~.0..\~.~. 4 Citizenship : f~~.0j. 5 ate of Birth: !.o.:.+...I.J.~.~.5... ay / Month / Year 6 Place of Birth:?O'J".c?~..H~:8..!..1~.01.!:-:0.ry.9.. Province / Country t~6 Kl,orv@10 t{-kl.ongptflf R. 7 Home Address:... Y. ')'. KHO/-fO/'J<3 ita I Yfl1-0oNGkHt--fI qo{/o 7 /. 8 Profession or Occupation:?.1.v...~.r(.T ~. 9 Passport (if refugee or stateless person should state the title of Travel ocument) No:..A..~..t.~.~?4:2.4-lssue at: 1~J.pj.}.?!.Fy.~.f.J9..R.~r.G.~.~.F.~0J.R.S.... On:.O.?:... r.,~.tv...l S(l ('J i.0 9-:!? Valid until:. 10 Estimate date of arrival in Malaysia:...,. 11 Address during stay in Malaysia: 12 Reference in Malaysia, if any: (Pra-SPM) Name: Address:..~.~.:!.0.1~.0..j'-..~.01.P.~.('Jq.7..~y0..l-:.0..~Y/:!.f.Y..~..?O{j ro Relationship to Applicant: Telephone No : Marital Status: If married, state name if wife / husband: :-:-. 13 Particulars of children who will be accompanying applicant: Name Sex ate of Birth Place of Birth... -
2 I' ~ 14 etails-of academic qualification (. to n''v\~'l-i ~, -6 ) i..,..~j(t~..,..0..~.h.,q.~.,l~,.,(.~.~1.y.0.j...ia1, S.,.,}.0.~"t~.\:.(~I ii,..?~m.,(j..~.l- ') iii. ", ',.,",..".,'.,..,"",'..',..,..,,', "..,.,,..,,..",. iv. "",.,"""""'".,.""."".",.',.,'.,,.,..,..',.,..".,.,.",,."..,..",.."..",. v, ",.,"',.,",.".,'..,.,"',.".,"',.,..,"',"",.,".,",."."., "..,.,..,',.. "..,"""','".",. (Please bring alqng oriqinal copies during submission of this form) 15 I have been accepted for admission G 0.) a J... " ~Jt1LI11t..0k UC\IN(R~l'Y (qi~~~c()~f\rv\= nl),qj(')tij1j'yl") (a) University,,,,.., ",,,,,',..,, 1 (b) College:.',..,..,."., "..,,..,.,.., ",'.., ',.,..,, '.,..,,. (c) Other: (please attach a copy of documentary proof of acceptance by above institution) 16 Finance Resource Name of Institution: -:. Type of Account: Amount: (Please attach also relevant document which can verify financial resources) 17 I hereby declare that particular in the application are true. ate (Signature of Applicant)
3 Q/ - O"'~~v ~ ~ PFR\10HONAN ITNTl'K VISA No.,I' \ II.. 1. '!I i,d,ii \ '1\, Id. "t'l h.\'11.'''1l ',I i '\ i I. I 1> 1)1' \(; \;" n,t{ '\N( j)!,). ;,' J 2q MR\'-- \qqs ",IA 0I\'y (\ N \J?~,( c1tc,,{\', 0\\j\)E;N\ \V", 'I '/.c b jf11,..a ('V AI t> (1 r~d-) K'Uf\ \rt\l\)v<\ \I U?--,,.0 L1 50,~ l\\'io\1o{\lg- \t(\\~h-r 00NGt.( -\\,..(1 qo \ 0 },,. \\t(~"i \,.(1 \),11) I) 0 N Go k'rt L.-(1 ""1\-\ A ),-t..(-1 l\j " " K,\,I j"p:';'-'!i:.ll "" 1 I ~,. i,
4 ," GOVERNMENT OF MALA YSIA Immigration Ordinance 1959 (r.m. 12 of 1969) Immigration of Regulation, 1963 (P.LN.228/63) j'ersonal, BONI} (Regulation 18). WIIEREAS it is a condition of the issue of PROFESSIONAL VIS!,!, PASS to me \~\K. A\)(\\'I\ ~(\\Z I;) 1\ of yj~u~ 'l..\)\\<"\)nj\lt~\s11«that there be furnished by me/on behalf of the saicl\11r. (-\\)(\M ~AK'J(~ security in the sum RM~OO,(lOas a guarantee that lithe said tf\~" A\lAM \', (\ ~(sa will comply with the provisions of the Ordinance and of any Regulations made there under and with any conditions imposed in respect of or instructions endorsed on such pass. Now I, The Roval Thai Embassy' NRIC No of do hereby bind myself that l/said \l1 'K, (~\JArvl 'RA\\ 0 fa wi comply with the provisions imposed in respect of or instruction endorsed on such PROFESSIONAL VISIT PASS. AN ill case of lithe said I'nR. 1~I)A(1J1 RAks(i making default therein, r hereby bind myselfto forfeit to the Government of Malaysia the sum ofrm~qo,oo ate this day of State ofwilayah PERSEKUTUAN Signature of the above named Signature and executed by the above named Royal Thai Embassy presence. in my Signature Full name of Witness: of Witness: Address of Witness:
5 Jenis Pas Iktisas Ix I Type of Pass Professional *Jenis Permohonan Type of APPlication A.MAKLUMATPEMOHON PARTICULARS OF APPLICANT 1. Nama Penuh (Huruf Besar) Full Name (Capital Letter) JABATAN IMIGRESEN MALAYSIA BORANG PERMOHONAN PAS LAWATAN VISIT PASS APPLICA TlON FORM PERATURAN-PERATURAN IMIGRESEN, 1963 [Peraturan 11 (12) dan 11 (15)]," Sosial Social Baru New Berniaga Business Lanjutan Extension 1M Pin. 1/97 Kerja Sementara Temporary Employment 6'11 J '\1 Gambar Pemohon Photograph Of Applicant (3.5 em x 5.0 em) [K] 3. TempatlNegara Lahir ',t{ttr L- (1 NO 2. *Jantina Lelaki Perempuan Gender Male Female Place/Country of Birth 4. **Tankh Lahir ate of Birth 19-s iwr \Cl.q, I 5. Warganegara It{fr1-- Nationality hari bulan tahun day month year' B. MAKLUMATPASPORTPERJALANAN/OOKUMENPERJALANAN PARTICULARS OF PASSPORT / TRAVEL OCUMENT 6. Jenis okumen Perjalanan Type of Travel ocument ' 7. Nombor Number 8. Tempat / Negara ikeluarkan Place / Country of Issue C. MAKLUMAT PENGANJUR 01 MALAYSI A PARTICULARS OF SPONSOR IN MALA YSIA 10. Nama Penuh (Huruf Besar) I ~Oq(1~~ \~{\1 t;()\'bas7't Full Name (Capital Letter). 11. No. Kad Pengenalan NRIC 9. "Sah Sehingga Valid Until 6 SAri 12. No. Telefon Telephone No. hari bulan tahun day month year 13. Alamat Address Negen State O. KEPERLUAN VISA VISA REQUIREMENT 14. *Adakah Visa iperlukan Visa Requirement 15. *Jenis Visa Type of Visa Tankh ate Ya [K] Tidak Yes No Sekali Perjalanan Single Entry Multiple Entry Berulangkali Perjalanan Tandatangan Pemohon / Penganjur Signature of Applicant / Sponsor. Borang mi hendaklah ditaip. Tandakan (x) dalam petak yang berkenaan. This form should be typed. Mark (x) in the appropriate box. Format Tarikh 99/99/9999 ate Format IMMIYYYY
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