RESIDENCE APPLICATION FORM

1. Please complete the sections below and pay the Residence Application Fee of RM100
(non-refundable) upon submissions of this form. Late submission will delay the
application process.
Please affix recent
2. Please note that the allocation of rooms will only be processed once the applicant has photograph here
accepted an offer to study at XMUM.
3. Application is subject to room availability and the University reserves the right to
assign any other type of residence available.

Please tick (√): New Student Existing Student Student ID ____________________

PERSONAL DETAILS

Full Name Nick Name

NRIC/Passport No. Gender Male Female

Date of Birth Nationality

Programme Enrollment Month and Year

Email Address Mobile No.

Home Address

PARENT/GUARDIAN/NEXT OF KIN TO CONTACT IN CASE OF EMERGENCY

Name 01 Name 02

Relationship Relationship

Mobile No. Mobile No.

RESIDENCE RENTAL RATE

*The charges below are subject to changes from time to time

Please select your preference Room Type Rate Deposit (Refundable)

Twin-sharing Ensuite

Twin (Block D) RM340 RM500

Twin (Block LY) RM390 RM500

For further information, kindly visit XMUM website: http://www.xmu.edu.my or email to studentaccommodation@xmu.edu.my
 OTHERS

Name of Roomate (if applicable)

Roomate Mobile No. NRIC/Passport No.

Remark(s)

DECLARATION

I, _______________________________________________ (Student’s name) hereby acknowledge that:

1) All information given by me is correct, accurate and true to the best of my knowledge at the point of filling up this form
and I understand that any information given falsely or withheld will affect my application and/or agreement.
2) I understand that this accommodation application is subject to room availability and the University reserves the right
to assign any other type of accommodation available.
3) I have read the Residence Management Rules and Regulations, and agree to abide to the said rules and regulations.
4) I fully understand that I I violate any of the terms in Residence Management Rules and Regulations, the University may
take further disciplinary measures, including rental termination for repeated violations.
5) I understand that the monthly rental is EXCLUSIVE of electricity bills, which will be billed directly to me.
6) I am expected to behave in a manner consistent with the good reputation of the University, refraining from any
behaviour which could endanger human life or health, or cause damage to property, disturb order and peace in the
Residence, or curtail the rights and liberties of the other residence within the Residence.
7) I agree that my information will be protected in accordance with the Data Protection Act.
8) Inform that I :- do not have any medical conditions
have medical conditions (please attach Doctor’s letter)
disabilities

__________________________________ _________________________
Signature of the applicant/Student Date

FOR ACCOMMODATION OFFICER FOR FINANCE OFFICER

Received by Payment method

Date received Amount paid

Assigned unit Receipt no

Confirmed by Received by

PAYMENT METHOD

1) By CASH
2) Cheque or Bank Draft payable to:
XMU JIAGENG EDUCATION DEVELOPMENT SDN BHD
3) Bank Transfer:
Bank name: Public Bank Berhad Bank name: Maybank Islamic Berhad
Branch: KL City Main Office Branch: KLIA2
Account Number: 319-724-8410 Account Number: 5624-3250-5328
Swiftcode: PBBEMYKL Swiftcode: MBISMYKL

Xiamen University Malaysia (XMUM) reserves the right to change the information in line with updates, from time to time. Please check the
website: http://www.xmu.edu.my for the latest information.

April 2019