Direct Application Form - 2019 ENTRY

Course Title : Bachelor of Medicine and Bachelor of Surgery (MBBS) 5 years

Campus : Newcastle University Medicine Malaysia, Johor, Malaysia
Application Number: (Office use only) Student Number: (Office use only)

1. Personal Details 2. Additional

Country of Birth:
Title:
 Mr  Mrs Miss Ms Other
Race:
Name as it appears on Identity Card/Passport:
Religion:

IC Number (Malaysian citizens ONLY) Nationality: (Please state if you have dual
nationality)
1.
Passport Number: 2.
Country of usual permanent residence:

Name you wish to be known by: Emergency contact details:

Name:

Home address: Telephone number:

Address:

_______________________________________
Contact telephone numbers:
Do you have a physical or mental disability or any
Home:
special needs:
 Yes  No
Mobile/Handphone:
If yes, please provide details:
Email address:

Gender: ________________________________________
 Female  Male
Payment of fees (tick as appropriate)
Date of Birth: (example 27/05/1985) Yourself/Family
Day Month Year
 Your employer (please specify)
 Sponsor/please specify

NUMed/ADMS-MBBS-APP/008
3. Education and Qualifications

School or College Attended

School or College To From Full Time

Qualifications completed
If you have already achieved the qualifications and grades required, send a
certified copy of the qualification documents with your application.

Date of
examination or
awards
Month Year Awarding Subject Level of Result
Body Qual. Grade

Qualifications you are still studying

You will need to provide information on the grade (forecast results) your
school/college expect you to achieve.

Date of
examination or
awards
Mont Year Awarding Subject Level of Result
h Body Qual. Grade

NUMed/ADMS-MBBS-APP/008
English Language Qualification

Qualification (e.g. Date Overall Spoken Written Reading Listenin

IELTS, TOEFL, MUET) Grade g

4. Personal Statement

5. Criminal Convictions

If you have any criminal convictions, please tick this box and provide details
below. 

NUMed/ADMS-MBBS-APP/008
6. Reference – Enter the contact details of the person you have asked to
provide a certified reference.

Name of
referee:

Post/Occupation/Relationship:

Name and Address of School /College:

Telephone:

Email:

What you must tell the person writing your reference:

 The reference must be certified by the school or college.

 The following questions must be covered in the reference:

o Name of applicant reference is supporting.
o Full name of Referee.
o Occupation of Referee.

 How long and in what capacity have you known the applicant?
 Do you know of any reason why the applicant should not be enrolled in this University?
 Does this applicant have any criminal convictions that you are aware of?
 Provide details of examination results or predicted examination results for the applicant.
 If the applicant’s first language is not English, please comment on his/her level of
competence by grading each of the following areas as either Excellent; Good; Fair; or Poor.
o Written
o Listening
o Comprehension
o Spoken
o Reading
 Provide comments on the academic suitability of the applicant for the medicine programme
and any factors that may affect their ability to complete the programme.

 The reference must be received by Newcastle University Medicine Malaysia as soon as possible.
The reference must be sent to: admissions@newcastle.edu.my.
Or by post to:
Newcastle University Medicine Malaysia
No 1, Jalan Sarjana 1

NUMed/ADMS-MBBS-APP/008
Kota Ilmu, EduCity@Iskandar
79200 Iskandar Puteri, Johor
Malaysia

7. Declaration
 I warrant that the information on this form, or provided in support of my application,
is accurate and complete. I acknowledge that the provision of incorrect information or
the withholding of relevant information relating to my application might invalidate my
application and that the University may withdraw an offer of a place or cancel my
enrolment in consequence.

 Should the University determine that I have submitted a false document, I consent to
the University disclosing this information to other relevant institutions.

 I consent to any educational institution at which I have previously been a student

and/or my current or any past employer, providing Newcastle University Medicine
Malaysia with information which that institution or employer holds about me for the
purpose of Newcastle University Medicine Malaysia verifying my grades and/or
qualifications and experience.

 I accept that information provided by me will be retained by Newcastle University

Medicine Malaysia, and will be made available to Newcastle University and the federal
state government agencies, pursuant to obligations under the Private Higher Education
Act 1996 (Act 555).

 I agree to abide by the statutes, regulations and policies of Newcastle University.

 I give consent to the processing of my data by Newcastle University, which I

understand will be in accordance with the requirements of the Data Protection Act
1998.

 I have read and understood the above conditions and accept them fully.

Applicants Name:

Date:

8. Checklist (Please attached the following documents with your email

application)
 Copy of IC (Malaysian applicant)/Passport (International applicant).

 Copy of SPM result (Malaysian applicant)/Copy of O Level/High School result

(International applicant).

 Copy of IELTS, TOEFL or MUET, etc.

NUMed/ADMS-MBBS-APP/008
 Pre-U forecast result from college/institution (applicable to applicant that applies
without final result).

 Copy of Pre-U final result from college/institution.

 Written reference from your referee (your referee can also send the reference after
you have submitted your application form).

9. Restricted availability for interview

Provide details of any dates you would be unavailable for interview.
We will consider this information but we cannot guarantee that we will be able to fit an
interview around your availability.

10. Where did you hear about NUMed?

 Parent/friend  Internet search
 College/School  Facebook
 Education Fair  Newspaper advert or article
Please state which  Words of mouth
Fair_________________________  Other (please
state_____________________

International Applicants - please note:

Housemanship and Registration (International Graduates)

International Graduates may not be able to obtain a pre-registration internship in

Malaysia and you should therefore ensure that your own country will offer you a house
officer post after qualifying at NUMed. However, NUMed has an agreement, supported
by the Malaysian Medical Council (MMC), with the University of Malaya Medical Centre,
a university hospital, and an option to undertake the House Officer programme should
become available there for international students.

Newcastle University Medicine Malaysia is listed in the World Directory of Medical

Schools (WDOMS, www.wdoms.org/) maintained by World Federation for Medical
Education (WFME) and the Foundation for Advancement of International Medical
Education and Research (FAIMER). Our FAIMER School ID is: F0003188.

Decision by Admissions Team (Office Offer Conditions:

use only)

NUMed/ADMS-MBBS-APP/008
Application Received:

Reference Received:

Interview Venue: Qualification Documents verified:

Interview Date: Outcome of interview:

Interview Time:

Selector interviewers:

Complete and email this form to admissions@newcastle.edu.my

NUMed/ADMS-MBBS-APP/008