(USE CAPITAL LETTERS / GUNAKAN HURUF BESAR)

PART A : PROGRAMME APPLIED FOR / PROGRAM DIPOHON

Programme / Program Venue / Lokasi

PART B : PERSONAL DETAILS / BUTIR-BUTIR PERIBADI

Full Name (as per IC) / Nama Penuh (mengikut K.P):

I.C. /Passport Number / No. K.P / Pasport : Nationality / Warganegara :

Date of Birth / Tarikh Lahir : Race / Bangsa :

Status : Gender / Jantina :Married / Berkahwin Single / Bujang Male / Lelaki Female / Perempuan

Home Address / Alamat Rumah :

Postcode :Business / Correspondence Address (current) / Alamat surat menyurat :

Postcode :

Home Phone Number / Telefon Rumah : Office Telephone Number / Telefon Pejabat : H/P Number / Telefon Bimbit : Fax Number / Nombor Faks :

E-mail : ______________________________________________

Class

Matric No.

For office use only

APPLICATION FOR ADMISSIONPERMOHONAN KEMASUKAN

- -

- -

Please glueone passportsized photo

here /Lekat satu

gambar bersaizpasport disini

EDUCATION BACKGROUND / LATAR BELAKANG PENDIDIKAN

Name of University / College / School Qualification Awarded Year SpecialisationNama Universiti / Kolej / Sekolah Kelayakan Diterima Tahun Pengkhususan

EMPLOYMENT BACKGROUND / LATAR BELAKANG PEKERJAAN

Title of Job / Position Held (recent first) Name of Organisation Period (Month / Years)Jawatan Dipegang (Dahulukan yang terkini) Nama Organisasi Tempoh (Bulan / Tahun)

PROFICIENCY IN BAHASA MALAYSIA / KECEKAPAN BAHASA MALAYSIAPlease tick ( ) the appropriate box / Sila tandakan ( ) dalam kotak yang berkenaan

Excellent Good Satisfactory Weak Cemerlang Baik Memuaskan Lemah

Written CommunicationKomunikasi Bertulis

Oral CommunicationKomunikasi Lisan

PROFICIENCY IN ENGLISH LANGUAGE / KECEKAPAN BAHASA INGGERISPlease tick ( ) the appropriate box / Sila tandakan ( ) dalam kotak yang berkenaan

Excellent Good Satisfactory Weak Cemerlang Baik Memuaskan Lemah

Written CommunicationKomunikasi Bertulis

Oral CommunicationKomunikasi Lisan

Please explain why you applied for the above program. How can this program assist you in your career development? / Sila jelaskan mengapa anda memohon program ini. Bagaimana program ini dapat membantu anda dalam perkembangan kerjaya anda?

SPECIAL CIRCUMSTANCES / KEADAAN KHAS

Do you have any disability, impairment or long-term medical condition which may affect your studies?Adakah anda mempunyai sebarang masalah kesihatan atau rintangan fizikal yang mungkin akan memberi kesankepada pembelajaran anda? Yes / Ya No / Tidak If you do, please provide extra informationSekiranya ya, sila beri maklumat lanjut

FINANCIAL SUPPORT / SOKONGAN KEWANGANHow do you plan to support your studies / Bagaimana anda menyokong pengajian anda dari segi kewangan

Source / Sumber Please Tick / Sila tandakan ( )

Personal Finance / Kewangan Peribadi

Scholarship / Biasiswa

EPF / KWSP

Bank loans / Pinjaman bank

Others (please specify) / Lain-lain (nyatakan)

How did you find out about this program? / Bagaimana anda mendapat tahu mengenai program ini?

Please Tick / Sila tandakan ( )

Friends / Kawan-kawan

Family / Keluarga

Newspapers (please specify) / Surat khabar (nyatakan)

Education fair / preview (please specify) / Ekspo Pendidikan / Prebiu (nyatakan)

Others (please specify) / Lain-lain (nyatakan)

Person to contact in case of an emergency:Sekiranya berlaku kecemasan, sila hubungi:

(i) Relative / Keluarga (ii) Others / Lain-lainName : Name :Nama : Nama : Relationship : Relationship : Hubungan : Hubungan :Telephone : Telephone :Telefon : Telefon : H/P No : H/P No :Tel. Bimbit : Tel. Bimbit :

PART C : DECLARATION AND SIGNATURE / PENGESAHAN DAN TANDATANGAN

I declare that the information provided by me in this application form is true and correct. I acknowledge that IPD-OUM reserves the right to vary or reserves any decision regarding admission or enrolment made regarding the basis of incorrect or incomplete information.

Saya mengesahkan bahawa semua maklumat dalam borang ini adalah sahih dan benar. Saya bersetuju bahawa IPD-OUM berhak untuk mengubah keputusan berkenaan kemasukan sekiranya maklumat yang saya berikan adalah tidak benar atau tidak lengkap.

…………………………………. ……………………………..Signature of Applicant DateTandatangan Pemohon Tarikh

PART D : APPLICATION CHECKLIST / SENARAI SEMAK PERMOHONAN

No Item Check / Semak ( )1 All sections of the form must be completed and the declaration signed and dated Semua bahagian borang mesti diisikan dan deklarasi ditandatangani 2 Enclose one copy of I.C. Kepilkan satu salinan kad pengenalan 3 Enclose one certified copy of all academic certificates and transcript Kepilkan satu salinan sijil akademik dan transkrip yang disahkan 4 Attach TWO (2) passport sized photo. One photo to be attached to the application form. Please write your name and I.C number at the back of the photo. Kepilkan DUA (2) gambar bersaiz pasport. Satu gambar dilekatkan pada borang. Sila tulis nama dan K.P dibelakang gambar. 5 Enclose confirmation letter from current employer Lampirkan surat pengesahan dari majikan 6 Candidates who wish to withdraw from EPF, please enclose EPF statement Lampirkan salinan penyata KWSP sekiranya anda ingin membayar dari akaun KWSP anda 7 Enclose a non-refundable application fee of RM200.00 in the form of bank draft / money order / postal order made payable to METEOR LEARNING SDN BHD Kepilkan yuran permohonan RM 200.00 (tidak dipulangkan) dalam bentuk bank draf / kiriman wang / kiriman pos di atas nama METEOR LEARNING SDN BHD 8 Select T-Shirt Size / Pilih saiz T-shirt S M L XL XXL 9 Send completed application to : Hantar permohonan yang lengkap kepada :

Manager (Student Management) Institute of Professional Development Bangunan METEOR Open University Malaysia Jalan Tun Ismail 50480 Kuala Lumpur Tel : 03 - 2773 2000 Fax : 03 - 2697 8790 / 8791

For office use only

Admission Payment Details

Verified By :_______________ Date : ____________ Amount : _____________________________

Enrolled By :_______________ Date : ____________ Receipt No. : _____________________________