e- Education (USER EDUCATION PROGRAM FORM)

TO BE COMPLETED BY USER

DATE OF APPLICATION *

NAME *

DEPARTMENT / FACULTY / CENTRE / UNIT *

EMAIL ADDRESS *

STAF/MATRIC NUMBER *

TELEPHONE (H/P) *

TELEPHONE (OFFICE)

DATE OF CLASS REQUIRED *

Time (00:00): (START) *

Select (AM/PM) *

Time (00:00): (END) *

Select (AM/PM) *

PLEASE SELECT THE CLASS REQUIRED *

REMARKS

Minimum 5 persons for student/ No minimum limit for staff: LIMIT FOR STAF

PLEASE ATTACH LIST NAME IF NECESSARY

Please submit this form within 3 working days before the expecting date of class.

Further information, do not hesitate contact:

Person in charge: Pn. Wan Azura binti Radzuan

Telephone: 06-798 6245

Email: wnazurard@usim.edu.my

Your request will be confirm through email or telephone.