ADMISSION APPLICATION FORM(BORANG PERMOHONAN KEMASUKAN – “ROADSHOW/WALK-IN”)

A) PROGRAMME PREFERENCES (Program pilihan)

Diploma in Nursing (Nilai campus) Diploma in Medical Imaging (Nilai campus)

Diploma in Nursing (JB campus) Diploma in Operating Department Practice (Penang)

Diploma in Pharmacy (Nilai campus) Diploma in Health Information Management (Nilai)

Diploma in Pharmacy (Penang campus)

Foundation in Science (Nilai campus)

Diploma in Physiotherapy (Nilai campus)

Bachelor programme : Please use another form. (All Nilai)

B) PERSONAL PARTICULARS (Butir peribadi)

Full Name :(Nama Penuh)I.C. No. : Date of Birth : Umur :(No. MyKad) (Tarikh Lahir) (Age)Mailing Address :(Alamat Surat)

Marital Status : Gender :(Taraf Perkahwinan) (Jantina)Telephone No. : Mobile Phone No. : (No. Telefon Rumah) (No. Telefon Bimbit)E-mail :(E-mel)

C) EDUCATION BACKGROUND (Latar Belakang Pendidikan)

School Name : (Nama Sekolah)Sijil Pelajaran Malaysia (SPM / O-LEVEL / SMU III / SM 3) Year Attend :

(Tahun Ambil)

Result Bahasa Malaysia : Pendidikan Moral : Ekonomi Rumah Tangga :(Keputusan) Bahasa Inggeris : Pendidikan Islam : Ekonomi Asas :

Mathematics : Tasawwur Islam : Applied Science :Add. Mathematics : Sejarah : Others

(2):.......................................................................Science : Perdagangan : Others

(3):.......................................................................Physics : Geografi :Chemistry : Pend. Seni Visual :Biology : Prinsip Perakaunan :

KPJUC/APP-FOUND-DIP/AFAD/11(01) - Page 1 of 1

DATE OF PRINTING

DECLARATION (Pengakuan): I, hereby confirm that to the best of my knowledge, the particulars given above and all details given are true and accurate. I understand and agree that any misrepresentation of facts will hold me liable for instant dismissal.

.........................................................................

...........Signature (Tandatangan)Date (Tarikh)

D) FOR OFFICE USE

□ QUALIFIED □ NOT QUALIFIED □ RESERVED

CHECKED BY : APPROVED BY :

NAME : NAME :DATE : DATE :

KPJ Healthcare University College, Persiaran Seriemas, Kota Seriemas, 71800 Nilai, Negeri Sembilan. TEL: 06 7942692 FAX: 06 794 2662 KPJ College Johor: Level 24, Metropolis Tower, Jalan Dato’ Abdullah Tahir, 80300 Johor Bahru. TEL: 07 335 2692 FAX: 07 333 6392 KPJ College Penang: 565, Jalan Sungai Rambai, Seberang Prai, 14000 Bukit Mertajam, Pulau Pinang TEL: 04 538 2692 FAX: 04 5308695

1SAS-Garis Panduan Kemasukan Pelajar 2013

State (Negeri):