(435576-U)

ADMISSION APPLICATION FORM

PART A: PROGRAMME
PROGRAMME:
Intake Year:
Intake Month:

PART B: PERSONAL DETAILS
Surname
* Official Full Name
(as per MyKad /Passport)
MyKad No.
or Passport No.
Nationality
Race
Religion
* Gender

Date of Birth
Day
Month
Year
Correspondence
Address:
Home Address
(if different from
Correspondence
Address)
* Telephone No:
Fax No:
Mobile No:
* E-mail Address:

PART C: PARENT / GUARDIAN DETAILS
Title
Name
Company Name
Position
Address
Telephone No:
Fax No:
Mobile No:
E-mail Address:

PART D: ACCOMMODATION FOR OUTSTATION/INTERNATIONAL STUDENTS
The College will assist students in arranging for accommodation subject to availability.
Do you require assistance in seeking accommodation?
  
Other Preferences


PART E: ACADEMIC RECORDS
Type of School
Name of School
State
Country
 
Level of Studies Completed
Others
Year Completed
 
English Proficiency
Please specify
 
Current Studies
 Completed:
Name of Course
Institution
 
Subjects of Choice
for A-Levels /SAM:

PART F: * DECLARATION
I confirm to my best knowledge, the information given in this form is correct and complete. I agree to abide by the Terms and Conditions and Fees Regulation of Disted-Stamford College.