APPLICA TION FORM

710353-P

PHOTO

APPLICATION FOR ADMISSION

A.CHOICE OF PROGRAM ME OF STUDY 1st Choice

2nd Choice

A. PERSONAL DETAIL Name as stated in the I/C / Passport In capital letter Citizenship

Gender Male

Date of birth:

Age:

Female

Marital status Single

Married

Others

Identity Card/ International Passport No:

Date of Expiry:

Date & Place Issue :

Country/State of Origin:

Country of Residence:

Religion:

Denomination/ Madzhab:

Ethnic origin (Malaysia only):

Postal Address

Pos/Zip code:

City:

State:

Telephone No:

Country:

Fax No:

Email Address :

Permanent Address (if different from the above)

Post/Zip Code:

State:

City:

Country:

B. FAMILY DETAILS Name of Father / Mother /Guardian

Identity Card/Passport No:

Citizenship:

Occupation:

No. of Dependants

Telephone No:

Monthly Income: (USD or RM)

Fax No:

C. EDUCATION (Please attach photocopy of transcripts)

Date Awarded

CGPA/Class

Qualification

Name of School/Colleges/University

To

From

To

From

D. WORKING EXPRIENCE Previous Employment (kindly attach supporting documents) Monthly salary

Position Held

Employer Name & Address

(RM or USD equivalent )

For Office Use Only

Reference No

Processing Fee

Date Received

Admission Qualification:

Date of Verification:

Country Code:

E. ADDITIONAL INFORMATION i. Have you ever studied in any institution of higher learning? Yes (If Yes, please fill in this Section)

No

ii. Name and Address of the institution(s) iii. Reasons for leaving Study/Course completed

Dismissed

Withdrew

Others

If Others, please state: __________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ iv. Transfer of Credit: If you wish to apply for transfer of credit, please submit your course outline, course structure and grading system to our office together with your application form. v. How did you get to know about MEDIU? Please state.

F. DECLARATION I hereby attest that I have personally filled in this Application Form and the information contained herein is complete and accurate to the best of my knowledge. I understand that withholding or giving false information will make me ineligible for admission and future enrollment. I further understand that I may be required to appear for an interview or to undergo such test as requested by the University Board of Admission as a condition for admission into the programme of study for which I have applied.

Applicant’s Signature: _________________________________

Date: _________________________

CHECKLIST FOR UNDERGRADUATE APPLICATION FORM Please submit all the following items along with the Application Form to ensure that your application is complete and can be processed for admission. Please tick (/) in the appropriate boxes to indicate items that have been attached.

i.

Non-refundable application processing fee of USD5.00 in a form of bank draft or telegraphic transfer (TT) or cashier’s order payable to Al-Madinah International Malaysia Sdn. Bhd and drawn at Maybank Berhad , (applicable to international applicants residing outside Malaysia) Or RM15.00 (applicable to applicants who submit application forms in Malaysia)

ii.

Academic certificates and examination results ( if your certificates and examination result slips are in language other than Malay, English Or Arabic, please submit certified true copies of the translation)

vii.

2 copies of Identity Card (IC) or Passport

viii.

4 recent passport-size, color photographs;

x.

Financial Statement;

xi.

Any other relevant documents. Upon completion, this form should return to : Admission Office Al-Madinah International University 11th Floor, Plaza Masalam2, Jalan Tengku AmpuanZabedah E/9E40100 Shah Alam, Selangor MALAYSIA Fax: +603 55113940 Email : [email protected] Any enquiry, contact : +603 55113939 (Malaysia)