APPLICATION FORM FOR UNIVERSITY ADMISSION

APPLICATION FORM FOR UNIVERSITY ADMISSION
Method of Enquiry:
Intake:
January
Walk-In
May
Referred by / Agent: __________
September
Others__________
Year ____________
ATTACH RECENT
PHOTO
Student Applicant (Malaysian)[checklist]
The following documents and Application Fee must be submitted with your application for admission
1. Certified True Copies of all Academic Qualification Certificates e.g. . SPM / O Level /
YES
NO
|  |
|  |
|  |
|  |
STPM / A Level / CIMP / SAM / Others..................................
2. Two (2) Certified True Certified True Copy of Identity Card
3. Application Fee (non-refundable) of RM100.00 payable to “Quest International University Perak”
Bank Name: CIMB Bank Berhad
Account Number: 8601255202
|  |
|  |
4.
Proof of English Language Proficiency e.g. MUET, IELTS or TOEFL, if applicable
|  |
|  |
5.
Four (4) Passport-Sized Photographs (blue background)
|  |
|  |
Note: Please write applicant’s name on the bank transaction slip and send it with the Application Form to
QIUP
Application Form for University Admission | Page 1 of 6
PROGRAMME APPLIED FOR (please tick)
Foundation in Science (A 9504)
Foundation in Business (A 9505)
Bachelor of Computer Science (Hons) (A 10305)
Bachelor of Business Administration (Hons) (A 10306)
Bachelor of Business Administration (Hospitality & Tourism Management) (Hons) (PA 2255)
Bachelor of Accountancy (Hons) (PA 1732)
Bachelor of Arts (TESL) (Hons) (PA 2258)
Bachelor of Medicine & Bachelor of Surgery (MBBS) (PA 0241)
Bachelor of Finance (Hons) (PA 2256)
Bachelor of Engineering (Hons) Electronics & Communications Engineering (PA 2259)
Bachelor of Science (Hons) in Biotechnology (PA 2343)
Bachelor of Corporate Communication (Hons) (PA 4518)
Diploma in Hotel Management (PA 3705)
Diploma in Business Management (PA 3706)
Diploma in Accountancy (PA 3703)
Diploma in Tourism Management (PA 4596)
Master of Business Administration (PA 3704) Part Time [
] / Full Time [
]
PERSONAL PARTICULARS
Name as stated in the NRIC / Passport (in capital letters):
Gender:
Male
Female
Nationality:
Date of Birth:
Age:
Marital Status:
Single
NRIC / Passport No:
Race:
Religion:
Married
Others
Application Form for University Admission | Page 2 of 6
CONTACT DETAILS
Postal Address:
Post / Zip Code:
City / State:
Country:
Home Tel No:
Mobile Phone No:
Email Address (compulsory):
PARENT’S / GUARDIAN’S PARTICULARS
Parent / Guardian
Name: (as in NRIC / Passport)
NRIC / Passport No:
Correspondence Address:
Home Tel No:
Office Tel No:
Mobile Phone No:
Postcode:
Email Address:
Employer:
Monthly Income:
Occupation:
Relationship (if guardian):
Emergency Contact (other than parents)
Name: (as in NRIC / Passport)
Relationship:
Correspondence Address:
Home Tel No:
Office Tel No:
Mobile Phone No:
Email Address:
Application Form for University Admission | Page 3 of 6
ACADEMIC QUALIFICATIONS (Please attach supporting documents)
Institution
Qualification
Year
Please provide details of the subjects taken and grades obtained
Qualification:
Qualification:
Subject
Grade
Subject
Grade
English Language Proficiency
Examination
Grade
Year
IELTS
TOEFL
English 1119
MUET
SOURCES OF FUNDING
Financial Support
Self-sponsored
Sponsored by Institutions(please attach
supporting documents)
Others (please specify)
_____________________
Application Form for University Admission | Page 4 of 6
ACCOMMODATION
Do you need accommodation?
Yes
No
If “Yes”, indicate type of accommodation preferred:
Single room
Shared room
Note: Type of room preferred is based on availability
DECLARATION
Parent / Guardian
I, _____________________________________ hereby agree to pay all the required fees for the programme of study for
which the applicant is enrolled.
____________________________________
Date: ____________________
Signature of Parent / Guardian
Applicant
I declare that all the information stated in the Application Form is true and correct and all the documents that were
submitted upon registration are true copies of the original documents.
I understand that Quest International University Perak (QIUP) reserves the right to refuse admission or enrolment made
on the basis of incorrect or incomplete information.
I agree to abide by all the academic and administrative regulations of Quest International University Perak (QIUP).
____________________________________
Date: ____________________
Signature of Applicant
Please return this form to:
STUDENT ADMISSIONS & RECORDS DIVISION
QUEST INTERNATIONAL UNIVERSITY PERAK (QIUP)
No.227, Plaza Teh Teng Seng, Level 2,
Jalan Permaisuri Bainun
30250 Ipoh Perak Darul Ridzuan
Tel: 605 – 2490500 | Fax: 605 – 2490503 | Email: enquiries@qiup.edu.my | Website: http://www.qiup.edu.my
Application Form for University Admission | Page 5 of 6
FOR OFFICE USE ONLY
Student Recruitment Division
Counselled by,
Documents Complete
Documents Incomplete
Specify : Document to be certified on the Registration Day
_________________________________
Signature
Name:
Date:
Selection Committee / Dean / Director
Eligible and To Be
Offered
KIV
Rejected
(IMPORTANT : PLEASE SPECIFY THE ENTRY REQUIREMENTS THAT
MEET/DID NOT MEET THE REQUIRED ENTRY REQUIREMENT) :
_________________________________
Signature
Name:
Date:
Student Admissions & Records Division
Counselled by,
Documents Complete
Documents Incomplete
_________________________________
Signature
Specify :
Checked by:
Re-checked by:
Name:
Date:
Date:
Date:
Note : Admission and Records Division shall reserves the right to reject any application with incomplete documents/ information.
Application Form for University Admission | Page 6 of 6