OUTBOUND

UNIVERSITY OF MALAYA
STUDENT EXCHANGE PROGRAM (UMSEP)
Application Form For Outbound Program
Please attach
As Non-Graduating Student a recent
Please read the form carefully and fill in all sections before submitting one (1) copy to the passport-sized
International Student Centre (ISC) and one (1) copy to the respective faculty. photograph
Application must be accompanied with copies of relevant certificates/transcripts and
supporting documents. Omissions and illegible applications will not be processed.

A. CHOICE OF UNIVERSITY

No. University Country Date Length of Stay

B. DETAIL OF STUDENT
Full name as per IC :
Matric No. : Semester :
Date of Birth : New IC / Passport No. :
Date of Session : Gender (circle where applicable) : Male / Female
Postal Address :

E-mail :
Mobile No. :

C. PARENTS/GUARDIAN DETAIL (IN THE CASE OF EMERGENCY)

Name :
Relationship :
Postal Address :

Contact No. (Home) : Mobile No. :

D. LATEST EXAMINATION RESULTS

Semester Academic Session GPA CGPA

UM-PT01-PK01-BR027-(1)
 E. DETAILED INFORMATION ON PROGRAM OFFERED BY THE HOST UNIVERSITY
Courses Intended to Pursue:

Course Offered by Host University Equivalent Courses Offered by UM

Course Code Course Name Credit Course Code Course Name Credit
Hour Hour

Total Credit Hours Total Credit Hours

F. FINANCIAL IMPLICATIONS

Self-sponsored Scholarship/Loan *Require Financial Assistance

Note: Please where applicable

*Plea * Please indicate in detail the type and cost of assistance required. Kindly enclose documents such
as flight quotations/detail of expenses to support your request.

G. DECLARATION

I declare that all information stated in this application form is true and correct. I understand that if at
any time the information or part thereof stated in this declaration is found to be false, the university
has the right and authority to disqualify, or if I am already admitted, to terminate my studies. I agree
to pay to the sponsor any sum agreed/paid for on my behalf, if i withdraw or change dates/time of
departure.

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Signature Date

H. CONSENT FROM PARENTS/GUARDIAN

I ________________________________, parents/guardian of _____________________________

(Parents/Guardian name) (Student Name)
agree on her/his participation in University of Malaya Student Exchange Program. I hereby
acknowledge and agree that University of Malaya will not be liable in any way for any loss, injury,
sickness or damage may suffer by her/his whilst participating in the program and the consequence
of any negligent act or omission of University of Malaya.

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Signature Date
 I. RECOMMENDATION FROM DIRECTOR/DEAN

Approve Disapprove

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Signature Date

UM-PT01-PK01-BR027-(1)