Direct Application Form

Course Title: Bachelor of Medicine and Bachelor of Surgery (MBBS) 5 years Campus: Newcastle/Malaysia
Application Number: (Office use only) Student Number: (Office use only)

Year of entry (example 2010)

1. Personal Details
Title: Mr Mrs Miss Ms Other Name as it appears on Identity Card/Passport: Passport Number: Name you wish to be known by: Home address:

2. Additional
Country of Birth:

Nationality:

Country of usual permanent residence:

________________________________________ Do you have a disability/Special needs: Yes No If yes, please provide details:

Contact telephone numbers: Home: Mobile: Email address: Gender: Female Male Date of Birth: (example 27/05/1985) Day Month Year _________________________________________ Payment of fees (tick as appropriate) Yourself/Family Your employer (please specify) Sponsor/please specify

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

Mont h

Year

Awarding Body

Subject

Level of Qual.

Result Grade

Qualifications you are still studying

You will need to provide information on the grade (predicted grade) your school/college expect you to achieve.
Date of examination or awards

Mont h

Year

Awarding Body

Subject

Level of Qual.

Result Grade

English Language Qualification

Qualification (e.g. IELTS, TOEFL) Date Overall Grade Spoken Written Reading Listenin g

UKCAT
UKCAT ID Date of test Overall Score Abstract Quantitati ve Decision Verbal

4. Personal Statement

5. Criminal Convictions
If you have any criminal convictions, please tick this box.

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 o o

Name of applicant reference is supporting. Full name of Referee. 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 applicants 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 o o o Listening Comprehension Spoken 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 sent to : ukdegrees@mabecs.com OR TO MABECS Sdn Bhd, Malaysian British Educational Cooperation Services, No. 9, 2nd Floor, Jalan Barat, 46200 Petaling Jaya, Selangor Darul Ehsan, 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, 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 NUMed Malaysia with information which that institution or employer holds about me for the purpose of Newcastle University NUMed Malaysia verifying my grades and/or qualifications and experience. I accept that information provided by me will be retained by Newcastle University NUMed 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. 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.

Decision by Admissions Team (Office use only) Application Received: Reference Received: Interview Venue: Interview Date : Interview Time : Selector interviewer: Offer Conditions: Qualification Documents seen: Unsuccessful: Reason for unsuccessful:

Complete and email this form to ukdegrees@mabecs.com