APPLICATION FORM

IIUM ACADEMY OF GRADUATE AND PROFESSIONAL STUDIES

A: Personal Information

Full name as in IC/Passport Sex

Mr KAMAL BIN ISMAIL √ Male

 Female
Citizenship Date of Birth (dd/mm/yy) Passport No IC No (Malaysian only)

MALAYSIAN 30/07/1971 Expiry Date 710730-11-5149

Religion Ethnic Origin Marital Status State of Residence (Malaysian only)

(Malaysian only)
ISLAM  Single NEGERI SEMBILAN
MALAY √ Married

Mazhab

SHAFIE

Postal Address

203 JALAN WP A8, TAMAN WARISAN PUTERI,

SEREMBAN, NEGERI SEMBILAN
Postcode: 70400
Telephone No (incl. country & area code) Fax No Email 1 hjkamal203@gmail.com

Mobile No (incl. country & area code) Email 2

60176150169
Permanent Address (in your country of residence)

AS ABOVE
Postcode:

Telephone No (incl. country & area code) Fax No Disability (please indicate any disability that may require
special arrangement)
Mobile No (incl. country & area code)

Current Company Name & Address

SK. TAMAN PAROI JAYA,

SEREMBAN,
NEGERI SEMBILAN

Postcode: 70400
Designation Telephone No Fax No

TEACHER 06-6793241

Page 1 of 5
Page 1 of 5
B: Choice of Programme
Please choose 3 programmes and write your preference with numbers 1, 2 and 3, 1 being your first choice:

M. Ed in Educational Management & Leadership

M. Ed in Teaching of Arabic to Non-Arabic Speakers

M. Ed in Teaching of Islamic Education

M. Ed in Educational Psychology

M. Ed in Curriculum and Instruction

M. Ed in Social Foundation of Education

M. Ed in Instructional Technology

M. Ed in Teaching Thinking

M. Ed in Teaching of English as Second Language (TESL)

INTAKE OPTION: Please tick ONE only:

1. Part Time (Malaysians only)

 Sept. ( )  Feb. ( )  June ( )
2. Full Time
 Sept. ( )  Feb. ( )  June ( )

C: Education Information

Bachelor’s Degree Other (1) Other (2)

Programme / Qualification

Major / Specialization

Class / CGPA / % / Division

From: From: From:

Period of Study (month/year)
To: To: To:

Year of Graduation

Name of University / Institution

Medium of Instruction

Important note: Please provide copies of all certificates and transcripts.

Page 2 of 5
D: English Language Proficiency

Test Date Taken Band / Point

TOEFL
IELTS

Important note: Please provide a copy of the test result if you have one.

E: Career Information
Name of Organization Position Held Duration ( Year from – to)

F: Financial Statement

How do you plan to finance your studies at the IIUM ACADEMY?

 Self / family sponsored

 Company sponsored

Company name:

 Scholarship / Award

Sponsoring Organization:

 Others

Relevant documents from your sponsor MUST be attached to support the information given.

For international applicants only: Self / family sponsored, please provide a verification letter and a
salary / bank statement as evidence of the applicant’s ability to cover tuition fees, books, living expenses etc.
Your application will not be processed without this document/declaration.

Please note that:

1. Malaysian Immigration Law requires international students to be enrolled as full-time students.

2. International students are NOT permitted to work while in Malaysia. A work permit is not issued
to a foreigner with a Student Visa/Pass.

Page 3 of 5
G. Acknowledgement

I hereby acknowledge that all the information provided above is true and has not been willfully distorted.
Should any of this information be found to be untrue or misleading, IIUM reserves the right render my
application null and void.

I also understand the programmes managed by IIUM ACADEMY are not subsidized by the Government and
hence the fees are higher than the fees applicable to the normal on-campus students.

Signature:

Name:

IC / Passport No:

Date:

Important:

Application with missing / incomplete information will not be processed. Please refer to the checklist
attached.

Page 4 of 5
 APPLICATION CHECKLIST

A complete application package should consist of the following items (please tick):

For Malaysian Applicants

 Copies of Degree Scroll/Certificate.

 Copies of academic transcript(s) / mark sheet(s) or other academic records.

 Other relevant documents (if any).

 TOEFL or IELTS result (if any).

 Letter / documents from sponsor (if any).

 A non-refundable application commitment fee of RM50.00 in bank draft, money order or postal order,
payable to UNI AKADEMIA CONSULTANCY.

Account Name: UNI AKADEMIA CONSULTANCY Bank: CIMB BANK

Account Number: 8603268830

*Certified English translation of documents that are not in English or Bahasa Malaysia.

Important note:

Please submit the completed application form BEFORE 30 OCTOBER 2018. Applications received after the
deadline will be processed for the next following intake.

Page 5 of 5