USM GLOBAL Extension
FELLOWSHIP Application Form
USM Global Fellowships: Please forward the completed form to your School/Centre/Institute for evaluation
purposes. DO NOT forward this form to the Institute of Postgraduate Studies.
A. APPLICANT’S PARTICULARS
1. Name :
2. I.C / Passport No. :
3. Matric No :
4. E-mail :
5. Contact Phone Number :
6. Registration date :
7. School/Centre/Institution :
8. Duration of Previous Appointment(s):
a. First appointment
:
From
to
b. Second appointment :
From
to
c. Third appointment
:
From
to
d. Fourth appointment :
From
to
e. Fifth appointment
:
From
to
f. Sixth appointment
:
From
to
9. Main Supervisor
Name :
Email :
10. Co-Supervisor
Name :
Email :
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USM GLOBAL Extension
FELLOWSHIP Application Form
B. PUBLICATION(S) AND PROGRESS
Indicate details of your publication(s) in journals and provide 2 copies of your publication(s) and corresponding
documents with the respective journals/publishers.
No.
Title of Article(s) in reference format
Listing [ISI/ISSN/
SCOPUS/ OTHERS
(Please Specify)
Impact
factor
Progress : Please state:
[Draft Manuscripts/
Submitted/Under
review/Accepted/ InPress/Published]
C. OTHERS (Conference/Attachment/Proceeding/Musical Score/Other)
Please indicate details and provide 2 copies of the supporting documents.
No
Details
2
USM GLOBAL Extension
FELLOWSHIP Application Form
D.DECLARATIONS
D1. I declare that I am not a recipient of any other scholarship or financial aid.
Name
:
Signature
:
Date
:
D2.I certify that all the information given in this application is complete and correct to the best of my
knowledge.
Name
:
Signature
:
Date
:
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USM GLOBAL Extension
FELLOWSHIP Application Form
------ PLEASE DETACH AND FORWARD THIS SECTION TO YOUR MAIN SUPERVISOR -----Guideline To Supervisor : Please mail this confidential report directly to the Dean/Director of your
respective School/Centre/Institute.
E. SUPERVISOR’S EVALUATION
(Please tick the appropriate box)
Poor
Unsatisfactory
Satisfactory
Good
Very Good
a. Candidate’s Progress
b. Candidate’s
Performance in
Research
c. Any other comments:
Date:
Signature:
Name
:
(
)
Official Stamp :
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USM GLOBAL Extension
FELLOWSHIP Application Form
------- PLEASE FORWARD THIS FORM TO YOUR DEAN/DIRECTOR FOR ENDORSEMENT BY SUBMITTING
YOUR APPLICATION TO :
DEAN/DIRECTOR OF YOUR SCHOOL/CENTRE/INSTITUTE -------GUIDELINE FOR SCHOOL/CENTRE/INSTITUTE
Please forward 1 copy of the endorsed extension form together with the endorsement form (provided
by IPS) to the Dean, Institute of Postgraduate Studies, Universiti Sains Malaysia, 11800 USM, Penang for
the final approval.
Thank you
F. ENDORSEMENT BY SCHOOL/CENTRE/INSTITUTE DEAN’S / DIRECTORS’S
Approved for extension
for USM Global Fellowship
Not approved for extension
for USM Global Fellowship
Comments:
Date:
Signature :
Name
:
(
)
Official Stamp :
5
USM GLOBAL Extension
FELLOWSHIP Application Form
----- FOR IPS OFFICIAL USE ONLY ------
E. THIS SECTION IS FOR THE INSTITUTE OF POSTGRADUATE STUDIES’S OFFICIAL USE
Endorsement by Dean of Institute of Postgraduate Studies
Approved for Extension
Not approved for Extension
Comments:
Date:
Signature :
Name
:
(
)
Official Stamp :
6