APPLICATION FOR ENROLMENT

Application for: Diploma in Nautical Studies (Deck Cadet)

A) PERSONAL PARTICULARS:

Name (in full): MUHD SYAZLY B. MOHD SALLEH

Address: NO 14 JALAN TUNA,TAMAN SERI TENGGARA

Postcode 34200
Town / City: PARIT BUNTAR
State: Perak
Telephone (Home): 05 - 7173608 Gender: Male
Mobile Phone: 017 - 4325062

Date of Birth (dd/mm/yyyy): 6-Jan-1993 Age: 18

Citizenship: Malaysian Height (cm): 165

Weight (kg): 68
BMI: 24.98

Place of Birth: PERAK NRIC: 930106-08-6051

Religion: Islam Ethnic / Race:Malay

Email Address: kartellohello@ymail.com

B) ACADEMIC REQUIREMENTS:

SPM Exam Result

Year: 2010 Name of school: MRSM LANGKAWI

Subject Level Obtained in SPM

1) Malay Language A
2) English Language A+
3) Mathematics A
4) Physics C+
5) Additional Mathematics C+

C) QUESTIONS:
1) Are you a swimmer?
Answer: Yes

2) Are you wearing visual aids (spectacles or contact lens)?

Answer: Yes
If "Yes", please advise the degree of your visual aid : 75 (must <200 or 6/9)

3) Are you colour blind?

Answer: No
4) Are you suffering from any illness that may hinder you from attending any course?
Answer: No

5) Extra Curricula Acitivities:

5.1) Uniform Body FIRE BRIGADE CADETS
Position / Rank President/Vice President

5.2) Non-Uniform Body STUDENT DISCIPLINARY BOARD

Position / Rank Committee
 5.3) Sports BOWLING
Representing District/State

6) Hobbies:
Answer: SURFING INTERNET

D) PARENTS / GUARDIAN INFORMATION:

Father / Guardian's Name MOHD SALLEH B. MAT DISA

Occupation: RETIRED

Telephone (Home): 05-7173608

Mobile Phone: 017-4325062

E) EMERGENCY CONTACT DETAILS FOR NEXT OF KIN

Name: MOHD SALLEH B. MAT DISA

Address:
NO 14 JALAN TUNA,TAMAN SERI TENGGARA,34200 PARIT BUNTAR,PERAK

Telephone (Home): 05-7173608

Mobile Phone: 019-4750532

Relationship: FATHER

F) OTHERS
1) If you are not successful to get a sponsorship, would you consider paying on your own for this programme?
Answer: No

2) Does your parent work for PETRONAS, MISC Berhad or its subsidiary?
Answer: No

If yes, please state :

Name
Relationship
PETRONAS/MISC/Subsidiary (if subsidiary, please state the name of the subsidiary)
Department
Designation

G) INSTRUCTIONS TO APPLICANTS
This form must be completed and submitted via email to (alam2011intake@alam.edu.my) before 1700hrs 4th APRIL
1) 2011 and a printed copy is to be brought along on the interview day (if you are successful) together with certified
photocopies of the following documents:-
a) Identity Card
b) School Leaving Certificates
c) SPM exam result

2) Please bring along RM10 for processing fee and RM80 for administrative fee (Total RM90) Postal/Money Order payable to
"Malaysian Maritime Academy Sdn. Bhd.".

3) ONLY shortlisted candidates will be notified for an interview via email.

4) Successful candidates will be required to attend the Candidate Fitness Assessment (CFA) which will consist of 6 physical
tests. Only candidates who are successful in the CFA test will be offered a placement for the course.

H) DECLARATION

I confirm and certify that the information given above (Please select) Agree
are true. I also agree that ALAM has the right to reject
my application in the event that the particulars given
are found to be untrue.

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