Online Application

To apply, please download the form (pdf document), fill it up, and fax it to any of the above numbers.
You can also fill up the form below and send it back to us online.
   
*Full Name:
   
Date: Click to select date
   
Identity Card Number:
 
Passport Number:
   
Correspondence Address:
   
Postcode:
   
Town:
   
Telephone Number (House):
   
*Telephone Number (Mobile):
   
*E-mail Address:
   
Recent Secondary School/College:
   
Highest Level Education: SPM
STPM
MATRICULATION
O-LEVELS
A-LEVELS
Others:
   
Course Interested: Predatory (Pre-Medic)
Dentistry
General Medicine
Pharmacy
   
Preferred Universities: 1.
2.
3.
   
*Consultant
   
Down Payment
Payment Method: