APPLICATION FORM

Campus:
Jalan Kuala Muda,
Mukim Padang Matsirat,
07100 Langkawi,
Kedah Darul Aman
Tel: +6 04 953 2020
Head Office:
49, The Boulevard,
Mid Valley City,
Lingkaran Syed Putra,
59200 Kuala Lumpur
Tel: +6 03 2730 5000
Fax : +6 03 2730 5050
1. Please read the TERMS & CONDITIONS before
completing the form & ensure that the form is Sila lekatkan
completed correctly. sekeping gambar warna
berukuran pasport /
2. Guidelines are provided on the last page of the
Please affix a
form. passport sized
3. Use a BLACK BALLPOINT PEN and write clearly in photograph
CAPITAL LETTERS. (Incomplete and illegible forms
will not be processed)

BUTIRAN PERMOHONAN / APPLICATION PARTICULARS

Kursus Yang Di Pohon / Course Applied For

Sesi Pengambilan / Intake Session

BUTIRAN PRIBADI PEMOHON / PERSONAL PARTICULARS

Nama / Name (seperti pada K/P / Pasport) (as stated in NRIC / Passport)

No K/P / Pasport / NRIC / Passport No Jantina / Gender

Lelaki / Male Perempuan / Female

Tarikh lahir / Date of birth Umur / Age Status Perkahwinan / Marital Status
Tahun / Year

Warganegara / Nationality Agama / Religion Bangsa / Race

Alamat Tetap / Permanent Adress

No Tel / Tel No No Faks / Fax No Poskod / Postcode

Alamat Surat-menyurat / Mailing Adress

No Tel / Tel No No Faks / Fax No Poskod / Postcode

No Tel Bimbit / Mobile Phone No E-mail / E-mail

LIC/A001-062013

Owned by Langkawi International College Sdn Bhd (623123-X)

49-11, The Boulevard, Mid Valley City, Lingkaran Syed Putra, 59200 Kuala Lumpur, Malaysia. Tel: +603 2730 5000 Fax: +603 2730 5050
Campus: Jalan Kuala Muda, Mukim Padang Matsirat, 07100 Langkawi, Malaysia. Tel: +04 953 2020 email:admin@lic.edu.my
 KELAYAKAN AKADEMIK / ACADEMIC QUALIFICATIONS

Kelayakan Sekolah / Institut Pengajian Tinggi Tahun Agregat / Gred / CGPA

Qualifications School / Institution of Higher Learning Year Aggregate / Grade / CGPA
SRP / PMR

SPM / SPMV / O-Level atau setaraf

SPM / SPMV / O-Level or its equivalent
STPM / A-Level atau setaraf
STPM / A-Level or its equivalent
Sijil / Diploma
Certificate / Diploma
Lain-lain (Sila Nyatakan)
Others (Please Specify)

BUTIRAN IBU BAPA/PENJAGA / PARENT/GUARDIAN PARTICULARS

Nama Bapa/Penjaga / Father's/Guardian's Name

No K/P / Pasport / NRIC / Passport No No Tel / Tel No

Umur / Age Pekerjaan / Occupation Pendapatan / Income

Tahun / Years

Nama Ibu/Penjaga / Mother's/Guardian's Name

No K/P / Pasport / NRIC / Passport No No Tel / Tel No

Umur / Age Pekerjaan / Occupation Pendapatan / Income

Tahun / Years

MAKLUMAT PEKERJAAN / EMPLOYMENT INFORMATION

Jawatan Majikan Deskripsi Pekerjaan Jangkamasa

Designation Employer Job Description Duration

Owned by Langkawi International College Sdn Bhd (623123-X)

49-11, The Boulevard, Mid Valley City, Lingkaran Syed Putra, 59200 Kuala Lumpur, Malaysia. Tel: +603 2730 5000 Fax: +603 2730 5050
Campus: Jalan Kuala Muda, Mukim Padang Matsirat, 07100 Langkawi, Malaysia. Tel: +04 953 2020 email:admin@lic.edu.my
PERAKUAN PEMOHON / DECLARATION

Saya mengaku bahawa segala maklumat yang diberi adalah benar. Saya akui bahawa pihak kolej berhak menolak permohonan ini
sekiranya maklumat yang diberikan tidak benar.

I hereby declare that all information provided in this application form and its attachments are true. I am aware that the college has the right
to reject my application for any false information provided here.

Tandatangan Pemohon Tandatangan Ibu Bapa/Penjaga Tarikh

Applicant's Signature Parent's/Guardian's Signature Date

DOKUMEN YANG PERLU DISERTAKAN / DOCUMENTS REQUIRED

Satu salinan kad pengenalan atau pasport / A photocophy of identity card or passport
Satu salinan sijil atau transkrip SPM atau kelayakan lain yang setara dengannya / Certified certificate or transcript of SPM or aquivalent
Satu (1) keping gambar terbaru bersaiz pasport / 1 passport size photo
Salinan sijil-sijil persekolahan dan lain-lain yang berkaitan / Photocopies of relevant certificates

Salinan slip gaji ibu bapa/penjaga

Any inquiries regarding application please call us at 04 953 2020 email at admin@lic.edu.my

FOR ADMISSION USE ONLY

Recorded By : Date :

Department :

Checked By : Date :

Department :

Remarks :

Owned by Langkawi International College Sdn Bhd (623123-X)

49-11, The Boulevard, Mid Valley City, Lingkaran Syed Putra, 59200 Kuala Lumpur, Malaysia. Tel: +603 2730 5000 Fax: +603 2730 5050
Campus: Jalan Kuala Muda, Mukim Padang Matsirat, 07100 Langkawi, Malaysia. Tel: +04 953 2020 email:admin@lic.edu.my