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: [email protected] | 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