STUDENT ADMISSIONS AND RECORDS UNIT

ACADEMIC MANAGEMENT DIVISION

REGISTRY DEPARTMENT
Photo
UNIVERSITI MALAYSIA PERLIS
(3 copies-one
3rd Floor, KWSP BUILDING, JLN BUKIT LAGI of them to be
01000 KANGAR, PERLIS, MALAYSIA pasted here)
Tel. : +604-9792984 / +604 9797940
Fax. : +604-9798703
E-mail : admission@unimap.edu.my

APPLICATION FOR ADMISSION TO UNDERGRADUATE PROGRAMME

1. Please complete in BLOCK CAPITAL in BLACK INK and tick boxes as appropriate.
2. All sections must be completed.
3. Incomplete application will not be entertained.
4. Two copies of the application form is required for each application

A. CHOICE OF PROGRAMME

First Choice
Second Choice
Third Choice
Fourth Choice
*The university have right to offer other programme subject to vacancies.

B. PERSONAL DETAILS

Name as stated in the Passport: (in capital letters) Gender:

Male Female

Title (Mr/Ms): Other name(s): Surname/Family Name: (as in Passport) Marital Status:
Single Married
Age: Date of Birth: Citizenship: Religion:
Islam Christian
International Passport No.: Date of Expiry: Date & Place of Issue: Hindu Buddha

Other:
Country of Residence: Country/State of Origin:

Postal Address:

Street: Post / Zip Code:

City/State: Country:

Permanent Address (Country of Residence):

Street: Post / Zip Code:

City/State: Country:

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Telephone No.: Fax No. (if any): E-mail Address:
(Compulsory)

C. FAMILY DETAILS

Name of Mother/Father/Guardian: Passport No.:

Occupation: Monthly Income: (USD) Citizenship:

Address: Telephone No.:

Fax No.:

E-mail :

Name of Contact In Case of Emergency: Passport No.:

Occupation: Citizenship:

Address: Telephone No.:

Fax No.:

E-mail :

D. LIST OF ALL SCHOOLS ATTENDED AND QUALIFICATIONS/DIPLOMA/CERTIFICATE OBTAINED

*(STARTING FROM PRIMARY LEVEL OR BASIC SCHOOL)

Type of
Date of Entry Date of Leaving Score/Grade/
Name of School Location/State/Country Certificate
(month & year) (month & year) CGPA/Division
Obtained

E. PROFICIENCY IN ENGLISH

Written : Good Fairly good Unsatisfactory

Spoken : Good Fairly good Unsatisfactory

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F. ENGLISH LANGUAGE ACHIEVEMENT (if applicable)

COURSE DATE TAKEN/COMPLETED SCORE

TOEFL

IELTS
Others (please state details)

G. FINANCIAL RESOURCES

Name of Sponsor:

Amount/year:

Correspondence Address:

Postcode: Country:

Relationship: Occupation:

Telephone No.: E-Mail:

H. REFEREES (other than family members and friends)

NAME POSITION ORGANIZATION/ADDRESS TELEPHONE NO./FAX NO./E-MAIL

1.

2.

I. DECLARATION

I hereby declare that all information and documents provided are true and complete. I acknowledge that Universiti
Malaysia Perlis may reject my application / withdraw the offer of admission if the information and documents provided
are found to be untrue or incomplete.

Applicant’s Signature: ________________________________ Date: ___________________

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J. CHECKLIST FOR UNDERGRADUATE APPLICATION FORM

1. Please submit all the following items along with the Application Form to ensure that your application is
complete and can be processed for admission. Please tick (/) in the appropriate boxes to indicate items that
have been attached.

 Certificate / Transcript of previous studies

(Certified true copies of all relevant academic transcript and examination results)

 English Language qualification certificate (if available)

 Personal medical health report (Compulsory)

 2 copies of Passport (first 3 pages including cover page)

* Please ensure the validity of your passport. MUST be more than 1 year

 3 copies of passport-size photographs (including one pasted on this form)

 Financial / bank statement of sponsor / parents (Compulsory)

 Receipt of processing fee payment (RM 110.00/USD 30.00)

2. All documents that are not in Malay or English must be accompanied by a certified English translation.

3. A receipt for processing fee payment receipt of RM50.00/USD20 in Postal/Money Order in Bank Draft in the
name of ‘Bursar, Universiti Malaysia Perlis’ MUST be submitted together with the application form.

FOR OFFICE USE ONLY:

Students Admission and Records Unit:

(Registrar’s Office)

Signature & Official Stamp:

Date:

Upon completion, this form should be returned to:

STUDENT ADMISSION AND RECORDS UNIT

ACADEMIC MANAGEMENT DIVISION, REGISTRY DEPARTMENT
UNIVERSITI MALAYSIA PERLIS
3rd FLOOR, KWSP BUILDING, JLN BUKIT LAGI
01000 KANGAR, PERLIS, MALAYSIA