FIRST SCHEDULE

(Subregulations 3(1), 6(2) and 9(2))

FORM A
PRIVATE HGHER EDUCATIONAL INSTITUTIONS
(PERMIT TO TEACH) REGULATIONS 1997
APPLICATION FOR A PERMIT TO TEACH
Registrar General of Private Higher Educational Institutions,
Ministry of Education.
I seek to apply for a permit to teach in a private higher educational institution.
2.

Enclosed herewith are

( a ) two copies of the application for a permit to teach;

( b ) two photographs with applicants name and Identity Card / Passport written on the back
( in addition to the photograph on the application form );
( c ) a certificate issued by a registered medical practitioner;
( d ) certified copies of the following documents ;
( i ) Identity Card / Passport;
( ii ) Work permit ( if relevant );
( iii ) Academic and Professional qualification certificates
( e ) Money Order / Postal Order / Bank Draft *no . for a sum of RM 20.00.

( Signature of Applicant )

MAISARAH BINTI ZAKERIA @ BAKRI[Type a quote from the

document or the summary of an interesting point. You can
800111-09-5002[Type a quote from the document or the
I.C. / Passport: ..
summary of an interesting point. You can position the text
Full name:

Date: ..

( * Delete where inappropriate)

PART 1
TO BE FILLED BY APPLICANT

1.

MAISARAH BINTI ZAKERIA @ BAKRI[Type a quote from the

Full name:

2.

Sex: ...

3.

Particular of Birth:

document or the summary of an interesting point. You can

FEMALE

__

PERLIS
Place of Birth : State: .
District: .
KANGAR

Town / Village: .

__

E 151815
Birth Certificate No.: ........
Date of issued: .
PERLIS

Place Issued: ..
4.

MALAYSIAN
Citizenship: .
800111-09-5002

I.C. / Passport no.: ...

Date of issues :
For Non Malaysian Citizens :
Date Of Expiry of Passport :
Work Permit no.:
Date of expiry of work permit :...

NO.6 JALAN DUA, TAMAN PADANG BEHOR, KANGAR, PERLIS.

5. Address :...

01000
012-4628033
Postcode : .............
Telephone no:
6. Particulars on academic and professional qualification:

No.
1.

2.

Name and address of

institution
UNIVERSITI
KEBANGSAAN
MALAYSIA BANGI
MAKTAB PERGURUAN
KUALA TERENGGANU

Entry date
MAY 1999

2006

Date of Completion
DECEMBER 2002

2007

Approval
DEGREE IN
SCIENCE
( STATISTICS )
DIPLOMA IN
EDUCATION

7. Working experience:

No.
1.

Name and address of

employee
INSTITUT
KEMAHIRAN
MARA BESERI PERLIS

From

Until

Designation

2005

2014

LECTURER

8. If you have applied for registration as chief executive or for a permit to teach please state :
Application reference no.: N/A.
Date of application: ...N/A
Decision on application: N/A...

Approved

Not approved

If not approved, please state reason: .

9.

Subject applied:

No.
1.
2.
3.

Subject
MATHEMATICS
TECHNICAL MATHEMATICS 1
TECHNICAL MATHEMATICS 2

Level of Study
3
3
3

10. Referee: (Please name referee who have known applicant not less than five years from the date of this
application. Referees cannot comprise closed family members. )

No.

Name and address of referees

1.

SALMAH ZAKARIA
INSTITUT KEMAHIRAN MARA
BESERI, 02400 BESERI, PERLIS.

Profession

Period referees has known

applicant

HEAD OF
GENERAL
STUDIES
DEPARTMENT

SINCE 2007

(Please attach referees supporting letters )

PART II
DECLARATION BY APPLICANT

MAISARAH ZAKERIA @
800111-09-5002
I ..Identity
card / Passport no :
BAKRI
( Name )
Do hereby solemnly declare that
( a ) the statements contained in this application form and the documents attached are true to the best of
knowledge and belief;
( b ) the signature written on this form is in my handwriting;
( c ) I have never been convicted of a charged in respect of
(i) an offence involving fraud, dishonesty or moral turpitude;
(ii) an offence under any law relating to corruption;
(iii) any other offence punishable with imprisonment for more than two years.
Signed and declared by me,
.
( Signature)

.
( Date )

my

PART III
TO BE FILLED BY THE REGISTRAR GENERAL
Decision of the Registrar General:
Approved

No.

Subject

Level of Study

Not Approved
Offical
Stamp

.
( Signature of the Registrar General )

( Date )

FOR OFFICE USE

APPLICATION APPROVED

Date of notification to the applicant: .

Permit to teach no. : ..
Signature officer: ..
Date: ..