STA Form

Science & Technology Award (STA)

Particulars of Nominee

* Full Name :

* Malaysian Identity Card No. (NRIC No.) :

* Title:
(eg. Assoc., Prof, Dr, Mr, Ms )

* Age :

* Gender :

* Email :

Office:

* Mobile:

* Present Position/Faculty/Department:

Particular of Recommending University/Institution

* Name:

* Others:

* Address:

* Name & Designation of Authorised Representative:

* Address of Authorised Representative:

Email:

Office:

* Field(s) of Specialization:
(Max: 25 Words)

* Upload Endorsed Application Form:
Rename the file name before upload.
e.g. STA_jamesloo_UM_2019

Particulars of Group Members (Max 4 Members)

*Please check the contents thoroughly before submitting online, as any alteration or re-submission thereafter will be rejected in total.