APPLICATION FORM

PART 1: Institution
Institution University of Cyberjaya Cyberjaya College Central Cyberjaya College Kota Kinabalu Cyberjaya College Kuching

PART 2: Academic Programme

Please attach
your recent
Certificate Degree
photograph here Programme
Foundation Postgraduate Programme

Diploma

Intake month year

PART 3: Personal Particulars

Name (as in MyKad / Passport) Date of Birth day month year

My Kad / Passport No Nationality

Home Address

Postcode Town / City Country

Gender Religion Race

Home Telephone No Mobile Phone No

Email Address

PART 4: Details of Family Members

No Name of Parents / Guardian & Siblings / Other Dependents Relationship Age MyKad / Passport Number Occupation
(as in MyKad / Passport)

01.

02.

03.

04.

05.

Household Income Parents / Guardian & Siblings / Other Dependents Contact Number

Parents / Guardian & Siblings / Other Dependents Email Address

PART 5a: Education Background - SPM /UEC / O-Levels / Year 11 equivalent

Name of School Telephone No

Address

Highest Academic Qualification SPM O-Level UEC

Others (Please specify) Year of Examination Overall Grade / Aggregate

Subjects and Results

No Subject Grade No Subject Grade

01. 06.

02. 07.

03. 08.

04. 09.

05. 10.
Note: Please attach certified true copies of examination certificates and result transcripts
 PART 5b: Education Background - STPM / A-Levels / Year 12 equivalent

Name of School Telephone No

Address

Highest Academic Qualification STPM A-Level SAM CPU Matriculation Diploma IB

Others (Please specify) Year of Examination Overall Grade / Aggregate

Subjects and Results

No Subject Grade No Subject Grade

01. 06.

02. 07.

03. 08.

04. 09.

05. 10.

PART 6: Academic Awards / Other Qualifications PART 7: Extracurricular Activities

No Name of Examination / Award Grade / Award No Name of Club / Society / Association / Activity / Event / Position Year

01. 01.

02. 02.

03. 03.

04. 04.

05. 05.

Note: Please attach certified true copies of examination certificates and result transcripts

DECLARATION BY APPLICANT

I hereby declare that the information provided in this application form is true and correct. I have read all information, terms and conditions and entry requirements for my programme of choice and
agree that the institution I am applying to reserves the right to change the criteria without prior notification. The final decision is at the sole discretion of the institution I am applying to. The
University/College reserves the right to reject this application if it is found to be false/misleading/untrue. I will not hold the University/College liable for any complications that may arise due to any
inaccurate information provided by me.

I consent to the processing by the University of personal data (including sensitive personal data as defined in the Data Protection Act 2010 (when applicable) about me for the proper purposes of the
institution. I consent to share my data among University of Cyberjaya and its affiliated colleges for the purposes of programme administration. I am also aware that the University/College shall protect
and manage my data in accordance with the University/College data protection and privacy policy.

Name of Applicant

MyKad / Passport No.

Date Signature of Applicant

PARENT / GUARDIAN’S APPROVAL - Applicants below the age of 18 will require the approval of their parent / guardian for the purpose of application.

Name of Parent / Guardian

MyKad / Passport No.

Date Signature of Parent / Guardian

FOR OFFICE USE ONLY

Verified & Checked By Interviewed By

Name Name

Date Date

University of Cyberjaya (DU053(B)) & Cyberjaya College Central (DK254-01(D)) Cyberjaya College Kota Kinabalu (DK254-02(S)) Cyberjaya College Kuching (DK254-03(Q)
UoC Campus, Persiaran Bestari, Cyber 11, Lot 33-40, Blok C, Plaza Juta, KM 7.2 Off Jalan Tuaran, Lot 51, Block 218, Jalan Batu Kawah/Jalan Stapol Junction,
63000 Cyberjaya, Selangor Darul Ehsan, Malaysia 88400 Likas, Kota Kinabalu, Sabah, Malaysia 93250 Kuching, Sarawak, Malaysia

Tel: +603 8313 7000 | Email: inquiry@cyberjaya.edu.my Tel: +6088 431 025 / 35 | Email: inquiry@kk.cyberjaya.edu.my Tel: +6088 431 025 / 35 | Email: inquiry@kuching.cyberjaya.edu.my
cyberjaya.edu.my kk.cyberjaya.edu.my kuching.cyberjaya.edu.my