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APPLICATION FORM
IMPORTANT

It is important that you complete ALL sections. Your application may be delayed if the form is incomplete.
Remember to attach all relevant additional information to your application.
Please complete in black ink and use BLOCK CAPITALS.

ADMISSION
You must obtain the following minimum scores in your five best subjects excluding Malay Language,
Islamic/Arabic/Moral Studies and Arts. We require you obtain A grades in at least five (5) main SPM/IGCSE subjects.

SPM

IGCSE

ARTS
English

Mathematics
3 other principals or core
subjects

A
A
B+ (in 2 out of the 3 principals B (in 3 principals or core
or core subjects with B in the subjects)
other)

SCIENCE
English

Mathematics
Additional Mathematics

A
A (but if not intending to
study Engineering : B)

A
A (but if not intending to
study Engineering : B)

B+ (in 2 out of 3 subjects)

B (in 2 out of 3 subjects)

Physics
Chemistry
Biology

PROGRAMME AND INTAKE


Kolej Yayasan UEM (KYUEM) has an annual intake:

a 24 months A-Level programme starting in July/August.


if you have qualifications other than SPM, you are still invited to apply.
you must be active in co-curricular activities.

SECTION A: PERSONAL DETAILS


Full name: _________________________________________________________________________________________
(Your name should appear as it does in your NRIC. Do not use abbreviations)

Family Name: __________________________ Gender: ________________ Race: _____________________________


NRIC/Passport No.: __________________Date of Birth: ________________ Place of Birth: _______________________
Nationality: __________________________Religion: _______________Mobile No: ________________________
Home Address: _____________________________________________________________________________________
____________________________________________________ Home No.______________________________

KYUEM only admits single students

E-mail : ________________________________________________
How did you find out about KYUEM?
Newspaper & Magazines

Education Fairs

KYUEM Website

Word of mouth or a family member who has attended KYUEM

KYUEM School Visits

Open Day

Other: ______________________________
(please specify)

SECTION B: PRESENT SCHOOL DETAILS


Name of School: _________________________________________________ SPM/IGCSE taken in Year: _____________
Address: ___________________________________________________________________________________________
Contact Person: ____________________________________________________ Contact No: ______________________

SECTION C: PARENTS/GUARDIAN DETAILS


Title:

Tan Sri

Puan Sri

Dato

Datin

Dr

Mr

Mrs

Ms

Father: ____________________________________________________________________________________________
NRIC/Passport No.: ___________________________________ Occupation: _______________________________
E-mail: _______________________________ Mobile No: _______________________Office No: ___________________
Title:

Tan Sri

Puan Sri

Dato

Datin

Dr

Mr

Mrs

Ms

Mother: ___________________________________________________________________________________________
NRIC/Passport No.: _____________________________________ Occupation: __________________________________
E-mail: _______________________________ Mobile No: _______________________Office No: ___________________
Guardian (if applicable): ______________________________________________Relationship: _______________
NRIC/Passport No.: ___________________________________Occupation: _______________________________
E-mail: _______________________________ Mobile No: _______________________Office No: ___________________

SECTION D: ACADEMIC ACHIEVEMENTS


SPM / IGCSE / EQUIVALENT QUALIFICATION (Please enclose certified copies of all certificates and transcripts)

Subject

Grade

Subject

1.

7.

2.

8.

3.

9.

4.

10.

5.

11.

6.

12.

Grade

SECTION E: CONDITIONS OF ENROLMENT


1. Details of the person or the sponsoring body responsible for paying the KYUEM fees:
Name: _______________________________________________ NRIC/Passport No.: __________________________
Relationship: _______________________________________Mobile No: ______________________________
2. Financial Understanding: I understand that I am obliged to make the payments for the college fees as stated on the
Payment Schedule of College and Registration Fee. I also understand that:
a)

All tuition fees must be paid in favour of Yayasan UEM by a crossed cheque, money order or bank draft.

b)

Tuition fees are charged by semester with fees due at the beginning of each semester.

c)

Any tuition fees paid for a semester are not refundable in the event that the student chooses to withdraw from
the college for any reason.

d)

Any tuition fees paid for a semester are not refundable in the event that the college dismisses the student for
disciplinary offences or for failures in academic performance.

e)

I hereby confirm that the person or representative named in Section E (above) will pay any due fees by the
date(s) stipulated by the college in their current financial schedules(s) and that, if there should be a default in
the payment of such fees, then KYUEM will have the right to withdraw the facility of all services (academic and
otherwise) from the student named in Section A of this application.

f)

Consent under the Personal Data Protection Act 2010 (PDPA)


I hereby give my consent for KYUEM to process my Personal Data (defined therein the PDPA) to review this
application and for the performance of the contract between the student and KYUEM including to transfer my
Personal Data to parties relevant for the performance of the contract. This consent shall remain applicable as
long as the Student maintains a contractual relationship KYUEM until such time the consent is withdrawn.

SIGNATURE OF PARENT / GUARDIAN / SPONSOR

Completed form must be sent to:

DATE

Kolej Yayasan UEM, Lembah Beringin, Selangor, P.O Box 62,


35900, Tanjung Malim, Perak Darul Ridzuan, Malaysia

HEALTH DECLARATION FORM


The following information will not adversely affect the application, so please provide a full and honest response.
Please () in the respective box if you have ever suffered from/experienced/received treatment for the following
diseases or conditions:
YES

NO

YES

NO

YES

Diabetes Mellitus

Heart Disease

Hepatitis B

Bronchial Asthma

Kidney Disease

Hepatitis C

Hypertension

Psychiatric Illness

Malaria

Hearing Problem

HIV/AIDS

Colour Blindness

NO

Please identify any learning difficulties that you have or have had and outline any special learning/support that you have
received.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Please provide details of any medication that you are currently taking or have previously taken.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Have you been hospitalised in the past 2 years?

NO

YES (if yes, please specify)

_____________________________________________________________________________________________

DECLARATION & CONSENT


I, declare that I do not consume drugs of any kind including alcohol and tobacco, all of which are banned substances for
students at KYUEM.
I, declare the above information given by me is true and complete. I hereby authorize Kolej Yayasan UEM to verify
information about me from whichever source you consider appropriate.
Consent under the Personal Data Protection Act 2010 (PDPA):

I hereby give my consent for KYUEM to process my Personal Data (defined therein the PDPA) to review this application
and for the performance of the contract between me and KYUEM including to transfer my Personal Data to parties
relevant for the performance of the contract. This consent shall remain applicable as long as I maintain a contractual
relationship KYUEM until such time the consent is withdrawn.
I further confirm that I have secured the consent of parties named under Section C, for and on behalf of KYUEM, for
KYUEM to process their Personal Data (defined herein the PDPA) to review this application and for the performance of
the contract between me and KYUEM including to transfer their Personal Data to parties relevant for the performance of
the contract. This consent shall remain applicable as long as I maintain a contractual relationship KYUEM until such time
the consent is withdrawn.
Thank you.

SIGNATURE

DATE