Passport-size

photograph
INTENSIVE ENGLISH PROGRAMME
REGISTRATION FORM
Checklist ()
Passport-sized photograph (with white background)
1 set photocopy of MyKad / Passport
1 set photocopy of original high school / college academic transcripts and certificates
Duration of Study
Preferred Starting Month*: ...............................................................
You will be allocated to class according to the class schedule.

Number of months desired to study on the programme ():-

2 month 4 months 6 months 8 months 10 months 12 months

IELTS Preparation (1 month) Ongoing monthly basis (payment must be paid monthly)
Personal Details
Title

Mr Mrs Ms Other:

as stated in the NRIC / Passport

Full Name
IC/Passport No.
Gender

Nationality

Date of Birth

Occupation

Telephone No.

Email Address

Mailing Address
In case of emergency, please contact:
Name
Relationship

Telephone No.

Would you like IUMW to help you find accommodation?

Yes

Acknowledgement

I hereby certify that the statements and

information in this application form are true and
correct to the best of my knowledge.

FOR OFFICE USE ONLY

Received by:
Referred from:
Placement test date:

_______________________________________
Name:
Date:

Class start date:

Proficiency level:
Allocated Lecturer:

Please return this form and required documents to

Centre of Language & Malaysian Studies or email to hassan@iumw.edu.my

No