700(HEA)/B.

PKPA-25


APPLICATION
FOR
ADMISSION









1. Please read the TERMS & CONDITONS before completing the form & ensure that the form is
completed correctly.
2. Guidelines are provided on the last page of the form.
3. Use a BLACK BALLPOINT PEN and write clearly in CAPITAL LETTERS. (Incomplete and illegible forms
will not be processed)
Please tick ( ) where applicable :

International Applicant
Intake : 1
st
session 2
nd
Session 3
rd
Session

PROGRAM CODE
First Choice : Second Choice : Third Choice :


1. PERSONAL INFORMATION Mr. Ms. Mrs.

Name as stated in IC/Passport


Other Name (if any)

I/C Passport Number Date of Birth
- - - -

Passport Details: ( For international applicant only )
Date of Issue Date of Expiry


Place / Country of Issue


Nationality


Gender : Male Female
Marital Status : Single Married
Disability : Yes No

Postal Address


Post code/Zip code: Town :
State :
Permanent Address (If different from above) :


Post code/Zip code: Town :

State :

Contact Number ( Please include all international codes )
Tel. No.(H) Tel. No. (HP)
Email Address :


Race : Religion :
Place of Birth :
(If Yes) Disability Type :

Please affix a
passport sized
photograph



( For international applicant only ) :
Language Spoken :


FOR INTERNATIONAL APPLICANT ONLY
Are you holding any type of Malaysian Visa now or have you held any before?(e.g. Student Pass, Dependent
Pass, Diplomatic Pass, ect)
No Yes

(Attention : Those transferring from another School/College in Malaysia and holding a Student Pass or
Dependant Pass will need to provide the School/College leaving Certification/Testimonial and academic
result and transcript)

Do you have a friend or relative in Malaysia? No Yes
If yes
Name :

Relationship : Tel. No. :
Address :

Post code/Zip code


Have you attended university before? Yes No
If Yes
Date Country University Name





Who will pay for your education expenses? :

2. PARENT/GUARDIAN INFORMATION

Name

Relationship : Occupation :
Tel. No. (H) : Tel. No. (HP) :
Tel. No. (O) : Fax. No. :

3. ACADEMIC / PROFESSIONAL QUALITIFICATIONS

Please list Schools/College that you have attended and professional qualifications that you have from age 15
(local applicant), age 7 (international applicant) and their result with a certified translation if the orginals are
not in English.
Year of
Examination
Name of
Examination
Total Number of Years Name of School/College Result






Please give details of any English Language qualifications you have obtained. Eg. MUET, IELTS or TOEFL
Year of Examination Name of Examination Result











(If Yes) type of pass : Valid Until :


List of Subject taken from your Highest Qualification and Grade/ Marks
Subject Division Grade/ Marks
A)Language English
Arabic
B) Mathematical
Related Subject(s)
Mathematics
Additional Mathematics
Calculus
Algebra
Geometry
Others (please state):
C) Science
Related Subject(s)
Science
Physics
Chemistry
Biology
D) Religious
Related Subject(s)
Islamic Studies
Others (please state):
E) Technical
Subject(s)
Computer
Others (please state):
F) Art subject(s) History
Geography
Literature
Others (please state):


Please enclosed the attachments below :

- Copy of passport (every page)
- Copy of transcript
- Copy of translated transcript to english
- Copy of other academic certificates
- Picture in pasport size 3 copy


4. DECLARATION

I hereby declare that all information provided is true. I am aware that the university has the right to reject
my application for any false information provided here.






Applicant Signature



Date :




Parent/Guardians Signature



Date :