e- Education (USER EDUCATION PROGRAM FORM)
TO BE COMPLETED BY USER
Email address *
DATE OF APPLICATION
MM
/
DD
/
YYYY
NAME
Your answer
DEPARTMENT / FACULTY / CENTRE / UNIT
Your answer
EMAIL ADDRESS
Your answer
STAF/MATRIC NUMBER
Your answer
TELEPHONE (H/P)
Your answer
PROGRAM DETAILS
1 hour for each class
DATE OF CLASS REQUIRED
MM
/
DD
/
YYYY
Time (00:00): (START)
Time
:
Time (00:00): (END)
Time
:
PLEASE SELECT THE CLASS REQUIRED *
REMARKS
Your answer
Minimum 5 persons for student/ No minimum limit for staff: LIMIT FOR STAF *
Your answer
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.
A copy of your responses will be emailed to the address you provided.
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