Application Form

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Malaysia Institute of Integrative Media (MIIM)
Prima Penisular Business Park
Block 6, Jln Setiawangsa 11
Taman Setiawangsa 54200 Kuala Lumpur
Any Enquiries please call: 603 - 20728598 or Fax: 603 - 20708823
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BORANG PERMOHONAN / APPLICATION FORM

Butiran Permohonan / Application Particulars

Kursus Yang Di Pohon /
Course Applied For:
Status Kursus / Course Status
Sesi Pengambilan /
Intake Session:

 

Butiran Peribadi Pemohon / Personal Details Of Applicant

Nama / Name:*
(seperti yang tertera di K/P / Pasport)
(as stated in your NRIC / Passport)		 En / Cik / Puan / Mr / Miss / Mrs
No K/P / Pasport / NRIC / Passport No:* (e.g. 020202-14-2020)
Jantina / Gender:*

Lelaki / Male                   Perempuan / Female
Warganegara / Citizenship:*

Umur / Tarikh Lahir / Age / Date of Birth:*
 Tarikh Lahir / Date of birth (dd-mm-yyyy e.g 20-02-2002)
Umur / Age Tahun / Years
Bangsa / Race:*
Alamat Tetap / Permanent Address:* Alamat / Address*
Jalan / Street* Bandar / City*
Negeri / State* Negara / Country*
Poskod / Postcode*
Tel / Tel:*       Faks / Fax:            
E-mel / E-mail:

Alamat Surat-Menyurat
Correspondence Address:
(jika lain dari yang di atas) /
(if different from above)

 

 

 

 Alamat / Address
Jalan / Street Bandar / City

Negeri / State Negara / Country
Poskod / Postcode

Tel / Tel:       Faks / Fax:            
E-mel / E-mail:

 

Kelayakan Akademik / Academic Qualifications
Kelayakan / Qualification Sekolah / Institusi Pengajian Tinggi /
School / Institution of Higher Learning		 Tahun / Year Agregat / Gred / CGPA / Aggregate / Grade / CGPA
SRP / PMR*
SPM / SPM(V) / O-Levels atau yang setaraf*
SPM / SPM(V) / O-Levels or its equivalent
STPM / A-Levels atau yang setaraf
STPM / A-Levels or its equivalent
SIJIL / DIPLOMA / CERTIFICATE / DIPLOMA
LAIN-LAIN / OTHERS
(Sila Nyata / Please Specify)

 

Butiran Pekerjaan (jika berkenaan) / Employment Particulars (if applicable)
Jawatan / Designation:
Organisasi / Organisation:
Alamat / Address:
Tel / Tel:             Faks / Fax:            
E-mel / E-mail:
Deskripsi Pekerjaan / Job Description:
Jangkamasa / Duration:

 

Butiran Ibubapa / Penjaga / Parents' / Guardian's Particulars
Nama Bapa / Penjaga / Father's / Guardian's Name:* Nama Ibu / Penjaga / Mother's / Guardian's Name:*
Alamat Surat-Menyurat / Correspondence Address: Alamat Surat-Menyurat / Correspondence Address:
Tel / Tel: * Tel / Tel: *
No K/P / Pasport / NRIC / Passport No:* No K/P / Pasport / NRIC / Passport No:*
(e.g. 020202-14-2020) (e.g. 020202-14-2020)
Pekerjaan / Occupation: Pekerjaan / Occupation:
Pendapatan / Income: Pendapatan / Income:
RM RM
Nama & Alamat Majikan/ Employer's Name & Address: Nama & Alamat Majikan/ Employer's Name & Address:
Tel / Tel: Tel / Tel:

 

Perakuan / Declaration

Saya mengakui bahawa segala maklumat yang diberikan adalah benar dan saya faham dan bersetuju untuk mematuhi Polisi Peraturan Am seperti yang dilampirkan.
I declare that all the information provided by me is true and I understand and agree to abide by the General Guidelines as attached.