MASTERSKILL COLLEGE OF NURSING AND HEALTH

PROGRAM ENTRY QUALIFICATION AND ENROLMENT VERIFICATION

FORM

DIPLOMA IN NURSING

Applicant’s Name:________________________________ I/C No.:_____________________________

No. ITEMS TO BE VERIFIED MARKETING DEPT. A&R DEPT.

1. SPM certificate produced Yes No Yes No

Year of SPM:_________

If not available, SPM results slip produced (less Yes No Yes No

than 2 years)

2. Pass in SPM subjects:

 Bahasa Malaysia Yes No Yes No

 Science subject Yes No Yes No

Please specify:_______________________

 Maths Yes No Yes No

 English Yes No Yes No

 3 Credits in SPM Yes No Yes No

3. Qualified for SPM certificate Yes No Yes No

4. Name and I/C no. verified against documents Yes No Yes No

5. Malaysian citizen Yes No Yes No

6. Applicant’s age below 30 years Yes No Yes No

7. Completed Forms (A001/ A002/ A003/ Yes No Yes No

A004/ A005/ A006)

8. Registration payment received Yes No Yes No

Amount received: RM_______

9. Payment made via

Cheque Bank Draft

Money Order Other: ____________

10. PTPTN Declaration Form signed
DECLARATION
I hereby declare that I have verified the above
documents and information and I understand that
the company reserves the right to terminate my
services if I am found to be negligent in
verifying the above documents and information.
Yes No
I have read and understood
the declaration stated herein
and confirm that the
applicant is Eligible / NOT
Eligible for this program.
(please specify)
Yes No
I have read and understood
the declaration stated herein
and confirm that the
applicant is Eligible / NOT
Eligible for this program.

Signature Signature
Name: Name:
Date : Date :