Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Rev No. : 2
Page No: 1 of 7
Ref.
No
(For Office Use)
Application Form
(For INTERNATIONAL STUDENTS ONLY)
Section A: To be completed by applicant (Please write in BLOCK LETTERS)
I. PERSONAL INFORMATION
1. Name (as in Passport): _________________________________________________________
2. Passport No:
4. Nationality: __________________
6. Marital Status:
7. Gender:
(dd/mm/yy)
(dd/mm/yy)
Single
Married
Male
Female
Islam
Buddhism
Hinduism
Christianity
Others________
(Please specify)
12. Do you suffer from any physical disability or illness? If yes, please specify the nature of
these conditions. Otherwise, state None.
____________________________________________________________________________
II. COURSE PEFERENCES
1. You can select up to a maximum of 5 choices. Please indicate your choice of courses in order
of preference.
No
Courses Preferred
1.
2.
3.
4.
5.
Rev No. : 2
Page No: 2 of 7
May
Others
Year: __________
Tick () if the medium of instruction was English (If it was not in English, please
provide a certified true copy of the English translation)
No.
Subject
Grade
No.
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
b)
Subject
Grade
(Please specify)
Tick () if the medium of instruction was English (If it was not in English, please
provide a certified true copy of the English translation)
No.
Subject
Grade
No.
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
Subject
Grade
Rev No. : 2
Page No: 3 of 7
Other Qualification(s): (If the certificate of award was not in English, please provide a certified
true copy of the English translation)
c)
Name of Award
Level of Study
CGPA/Grade
Year Awarded
Examining Body
Name of College/University/Institution
Address of College/University/Institution
2. English Language Proficiency:
IELTS
TOEFL
Score: _____________
Score: _____________
Score: _______________
:___________________________________________________________
2. Uniform
:___________________________________________________________
3. Clubs/Societies
:___________________________________________________________
V. PARTICULARS OF PARENT/GUARDIAN
Rev No. : 2
Page No: 4 of 7
V. PARTICULARS OF PARENT/GUARDIAN
VI. IMMIGRATION VISA
1. Do you hold any type of Malaysian Visa Now:
If yes, the type of Visa:
Social Visit
Yes
Student
No
Dependent
Diplomatic
(dd/mm/yy)
(dd/mm/yy)
Yes
No
Rev No. : 2
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___________________________
Name of Applicant
_____________________
Signature of Applicant
____________
Date
X. CHECKLIST
Completed application form must be submitted together with the following documents:
1.
2.
3.
4.
5.
6.
7.
8. 3 sets of photocopied Passport (All pages of your passport including blank pages); and
9. 6 passport-sized colour photographs;
10. Medical Report;
11. Bank Statement of the past 6 months;
12. Curriculum Vitae;
13. Institution Leaving Certificate/Testimonial, Release Letter, Results, Academic Transcript and
Attendance Report/Letter (Applicant transferring from another University/College in Malaysia
and holding a Student Pass or Dependent Pass)
5
Rev No. : 2
Page No: 6 of 7
Consent:
1. You hereby authorise and consent to us processing (including disclosing) your
personal data and any updates of your information, for the purposes and/or for any other purposes
related to the purpose.
2. If you do not consent or subsequently withdraw your consent to the processing and disclosure of your
personal data, UTAR will not be able to fulfil our obligations or to contact you or to assist you in
respect of the purposes and/or for any other purposes related to the purpose.
Rev No. : 2
Page No: 7 of 7
Incomplete:
Certificate/Birth Certificate
A
non-refundable
processing
Certificate/Birth Certificate
fee
of
____________________________________
A
non-refundable
processing
fee
of
____________________________________
Date: ____________________
Remarks: ______________________________________________________________________
B. Division of Programme Promotion/Department of Admissions and Credit Evaluation
Name of Staff-in-charge: __________________________
Date: ____________________
Remarks: ________________________________________________________________________