Applicant Name:

Bachelor of Medicine/Bachelor of Surgery (MBBS) Application for admission (Please state year)
Instructions:
1. Please fill out this form clearly in pen. Prospective students are encouraged to apply online at

www.monash.edu.my/advancement/future/
2. Enclose all supporting documentation with this application. (All documents must be certified by a recognised authority).

This application will not be processed unless full documentation is attached.

3. An application fee of RM100 (non-refundable) is payable on submission of this form. Bank draft is to be made payable to

MONASH UNIVERSITY SUNWAY CAMPUS. Cash is only payable at the Financial Services Cashier Counter.
4. You are required to refer to the Monash University Sunway Campus website at www.monash.edu.my/advancement/future/ for

admission deadlines.
5. (For international students only) Please note that strict deadlines have been set for international student applications to facilitate the student

pass processing. If the student pass application is successful, a Letter of Approval (from the Malaysian Immigration Department) will be sent to you. Only students who hold a valid student pass will be permitted to enroll and commence classes. 6. This application is the property of Monash University. Supporting documentation will NOT be returned. 7. It is your responsibility to advise Monash University Sunway campus regarding any change of address. 8. Send your application to: Prospective Students Office Monash University Sunway campus, Jalan Lagoon Selatan, Bandar Sunway 46150 Petaling Jaya Selangor Darul Ehsan, Malaysia Telephone +603 5514 6000 Email pso@monash.edu.my Website www.monash.edu.my

Office use only

Finance

Prospective Students Office

Student Recruitment

Application No:

ID No:

Course Code:

International Student Pass Unit:

Offer Acceptance Date:

Acknowledgement of receipt

Official reply to applicant

Reply to agent

Date
D D

Date

Date faxed
D

Section A: Your application

1. Are you a

! Malaysian

! Non-Malaysian

2. The application form was submitted by (please tick appropriate box)

! Self (direct application). Where was this application submitted? ! Monash representative/agent. Name of Monash representative/agent ! Other (eg. sponsor JPA, MARA, etc.) - attach supporting documentation. Name of other

www.monash.edu.my

MSC Status
Company

Section B: Personal details (Please state name as per passport)

We may contact you by email, post or telephone. To avoid delays in your application, it is important you complete ALL your details including your email address.

Title: (eg. Mr, Ms, Mdm) Given name/s NRIC/Passport number Date of Birth* Nationality *Religion Muslim Buddhist
D D M M Y Y Y

Family name/Surname

Sex
Y

Male

Female

*Note: Please refer to the University age requirements for admissions at www.monash.edu.my/advancement/future/

Country of Birth Hindu Christian Other. Please specify:

* For government reporting only.

Section C: Visa related information (for international students only)

Yes Are you currently in Malaysia? No If YES, please state your pass type (eg. student, dependent) : When does this pass and/or visa expire?
D D M M Y Y Y Y

Section D: Postal address for correspondence (or agents address where applicable)
Number & Street City/Town Country Phone (Home) Mobile number Email address (agent) State/Region Postcode Phone (Office) Fax

Home address (essential)

Number & Street City/Town Country Phone (Home) Mobile number Email address (own)* State/Region Postcode Phone (Office) Fax

Compulsory

Section E: Academic qualifications and other required documents Secondary studies

Part 1: SPM/O-Levels/Year 11 or equivalent - Please provide 2 certified copies of academic transcripts/ results Year obtained: Assessment / qualification type (eg. SPM/O-Levels/Year 11): Name of school/institution: Part 2: A-Levels /Year 12 or equivalent (eg. Pre-U) Please provide a certified copy of academic transcripts/ results Year obtained: State / Country: Assessment /qualification type (eg. A-Levels/CIMP/MUFY/etc): Are you currently awaiting results of any secondary or Pre-U studies? If yes, name of qualification and institution: Date on which the results will be available:
D D M M Y Y Y Y

State / Country:

Score / Result: Name of institution:

Yes

No

Bachelor of Medicine/Bachelor of Surgery (MBBS) Application for Admission

Tertiary studies
Please submit a certified copy of academic transcripts /results for ALL qualifications/academic studies, either currently enrolled, completed or discontinued, including failures (if any). Please use additional pages if space below is insufficient. Degree / qualification: Field of study/ Major/ Specialisation: Year commenced (MM/YY): State/Country: Institution: Year last attended (MM/YY): Did you complete? Yes Yes No No

Are you currently awaiting results of any post secondary or professional or tertiary studies? If yes, name of qualification and institution: Date on which the results will be available:
D D M M Y Y Y Y

Section F: Statement of activities and other academic studies

Have you engaged in or do you intend to study at another institution in Malaysia or overseas for the period from your last/most recent academic studies to the commencement of the intended intake? If YES, please state what activities you have/will engage in during this period. Yes No

If NO, please state what activities you have engaged/will engage in during this period.

Section G: Employment history

Please provide details of any employment experience that may be relevant to the course application. Supporting documentation (ie. CV or references) may be submitted. Please use additional pages if space below is insufficient. Occupation / Position: Start date:
D D M M Y Y Y Y

End date:

Employment type: Position and duties:

FT

PT

Employer name:

Occupation / Position: Start date:

D D M M Y Y Y Y

End date:

Employment type: Position and duties:

FT

PT

Employer name:

Section H: English language proficiency and aptitude test

Studying or studied English or ESL as a pre-university subject. English was the language of instruction in previous studies completed.
(Please note that this will not satisfy the English requirements for the MBBS) D D M M Y Y Y Y

Will sit/have sat for English language proficiency test (eg. TOEFL, IELTS). Date scheduled/taken English test name (if known): Result (if known): IELTS candidate ID: Will sit/have sat for ISAT aptitude test (this is a requirement for entry). Date scheduled/taken Result (if known): ISAT candidate ID: Other/provide details

(result certificate required)

(result certificate required)

Bachelor of Medicine/Bachelor of Surgery (MBBS) Application for Admission

Section I: Important checklist

Application form filled out in full and signed? Application fee attached? If applying for MBBS Clayton and MBBS Malaysia, only one application fee is required. *Payment in foreign currency must be based on applicable estimated exchange rates determined by the University from time to time. 2 certified copies of Secondary Education (SPM/O-levels/Year 11 or equivalent) 1 certified copy of Secondary Education (Pre-U, A-Levels, CIMP or equivalent) 1 certified copy of Tertiary Education (if applicable) English proficiency test result 1 copy of International Student Admissions Test (ISAT) result 1 copy of NRIC (for Malaysians only)

Section J: Important checklist for international students only

6 passport size colour photographs (3.5cmx 5cm- Head Size: 2.5cm x 3cm) 3 full and clear copies of ALL pages of your passport(s) only on A4 size paper including the blank pages** 5 full and clear copies of ALL pages of your passport(s)** (For students from Peoples Republic of China ONLY) ** It is highiy recommended that the passport be valid for the minimum duration of the course. If the passport is expiring within one year from the time an application is to be accepted, please apply for new passport and submit photocopies of ALL pages of BOTH passports. For applicants who have studied in Malaysia before: A certified true copy of your academic transcripts with information on the grading system* from your latest institution of study. *(E.g. A = 85% - 100%, etc.) A certified true copy of attendance report and a certified true copy of your certificate of completion from your latest institution of study. The original release letter signed by Chief Executive Officer from your latest institution of study, or an original letter certifying you as a student of your latest institution and the course in which you were enrolled. A certified true copy from your latest institution of study, of the highest academic qualification (i.e. transcript/ results/certificate(s)) from your home country.

Section K: Declaration
I warrant that the information on this form, or provided in support of my application, is correct and complete. I acknowledge that the provision of incorrect information or the withholding of relevant information relating to my application, including academic transcript/s, 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 tertiary institutions. I consent to any educational institution at which I have previosuly been a student and/or my current or any past employer, providing Monash University with information which that institution or employer holds about me for the purpose of Monash University verifying my grades and/or qualifications and experience. I accept that information provided by me will be retained by Monash University Sunway campus, and will be made available to Monash 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 Monash University. I have read and understood the above conditions and accept them fully.

Date
Applicants signature
D D M M Y Y Y Y

Office use only

Offer of Admission Additional comments (if any): Authorised by: Offer of Admission with conditions Offer Conditions - please state: Date:
D D M M Y Y Y Y

Rejection - No offer

Reason for rejection - tick appropriate box insufficient quota documentation unsatisfactory not qualified Authorised by: Date:
D D M M Y Y Y Y
KP(JPS)/5195/US/595(16) KP/JPS/DFT/US/B04 Prited April 2010

Authorised by: No

Date: Yes

Reconsideration Requested Outcome:

Offer Conditions Met Authorised by:

Authorised by: Date:

D D M M Y Y Y Y

Date:

Remarks:

Bachelor of Medicine/Bachelor of Surgery (MBBS) Application for Admission