Application Form Ver 8.2013 (Updated 2013-12-09 PDPA)

APPLICATION FORMAPP/

New application

Re-application

Waive Processing Fee

Important!· Please complete ALL SECTIONS in this form with BLOCK LETTERS. · Read Part M: Instruction Sheet (page 4) before completing this form.

PART A : APPLICANT DETAILS

Title Mr Ms Mrs Others please specify

Name (as in NRIC/Passport)

Correspondence Address

City Postal Code

State Country

Contacts Tel. no Mobile Phone no.

Email address

Nationality Malaysian PR please specify Others please specify

Ethnicity Malay Chinese Indian Others please specify

Religion Muslim Buddhist Hindu Others please specify

Gender Male Female

Marital Status Single Married Widow Divorce

PART B : PROGRAMME PREFERENCE

Please state the top three (3) programmes you would like to study by referring to the list below.

No Programme Code Programme Title Full/Part Time Partner School (if applicable) Intake

** Please refer to our brochure for the list pf partner schools if you are applying for the credit transfer option

LIST OF PROGRAMMES:

Medicine DentistryMED01 Bachelor of Medicine and Bachelor of Surgery (MBBS) IMU DTY01 Bachelor of Dental Surgery (BDS) IMUMED02 Bachelor of Medicine and Bachelor of Surgery (MBBS) PMS-Undergraduate DTY02 Bachelor of Dental Surgery (BDS) PDSMED03 Bachelor of Medicine and Bachelor of Surgery (MBBS) PMS-Graduate

Pharmacy Short CourseMPH01 Master of Pharmacy in collaboration with University of Strathclyde (2 + 2 option) CPD Continuing Professional DevelopmentMPH02 Master of Pharmacy in collaboration with University of Strathclyde (2.5 + 1 option)BPH01 Bachelor of Pharmacy (Hons) IMUBPH02 Bachelor of Pharmacy (Hons) Credit Transfer

Complementary Medicine, Health Sciences & NursingCME01 Bachelor of Science (Hons) Chinese Medicine IMU NUR01 Bachelor of Nursing (Hons)CME02 Bachelor of Science (Hons) Chinese Medicine Credit Transfer NSC01 Bachelor of Nursing Science (Hons) (Top-up Program)CHP01 Bachelor of Sciences (Hons) Chiropractic IMU NDT01 Bachelor of Sciences (Hons) Dietetics with Nutrition IMUCHP02 Bachelor of Sciences (Hons) Chiropractic Credit Transfer NDT02 Bachelor of Sciences (Hons) Dietetics with Nutrition Credit TransferBMS01 Bachelor of Science (Hons) Biomedical Science IMU NUT01 Bachelor of Sciences (Hons) NutritionBMS02 Bachelor of Science (Hons) Biomedical Science Credit Transfer PCM01 Bachelor of Sciences (Hons) Pharmaceutical ChemistryMBT01 Bachelor of Sciences (Hons) Medical Biotechnology IMU PSY01 Bachelor of Sciences (Hons) Psychology IMUMBT02 Bachelor of Sciences (Hons) Medical Biotechnology Credit Transfer PSY02 Bachelor of Sciences (Hons) Psychology Credit Transfer

Postgraduate StudiesPGT01 Master of Science in Analytical & Pharmaceutical Chemistry (Full/Part-Time) MSC01 Master of Science in Medical & Health Sciences (By Research) (Full/Part-Time)PGT02 Master of Science in Public Health (Full/Part-Time) PHD01 PhD in Medical & Health Sciences (By Research) (Full/Part-Time)PGT03 Master of Science in Molecular Medicine (Full/Part-Time)PGT03 Master of Science in Formulation Science (Full/Part-Time)

3

Y/ /M

2

1

Y Y Y

Passport Expiry Date / /D D M M

Passport Issue Date

Preferred name

Y Y Y Y

Place of Birth

Place of Issue

/ /M MD D

Y Y YDate of Birth

D

(For printing of Student ID Card - Only 16 characters including space)

D M

YNRIC/Passport No.

Application Form Ver 8.2013 (Updated 2013‐12‐09) Page 1

PART C : PARENTS / GUARDIAN DETAILS

Father's Name

Occupation


Email address

Mother's Name

Occupation


Email address

PART D : EMERGENCY / GUARDIAN CONTACT DETAILS

Contact Name Relationship


Email address

PART E : SPONSORSHIP / SCHOLARSHIP DETAILS

Are you applying to International Medical University on sponsorship/scholarship? Yes No

If you are a sponsorship / scholarship student, please state the name of your sponsor

PART F : ACADEMIC DETAILS

High School / O-Level / SPM / Year 11 Qualification Year of Completion

Name of High School State / Country

Pre-U Qualification (i.e. A-Level/STPM/Year 12/etc) Year of Completion

Name of Institution State / Country

Academic Results Actual results Forecast results

Diploma / Degree Qualification

Name of Institution

Grade/CGPA/Class Year of Completion

Postgraduate Qualification

Name of Institution

Grade/CGPA/Class Year of Completion

Chemistry

Name of Subject Grade

English Language

Name of Subject Grade Name of Subject

Mathematics

Additional Mathematics

Biology

Physics

Grade

Name of Subject (others, please specify) Grade


PART G : ENGLISH LANGUAGE PROFICIENCY

PART H : WORK EXPERIENCE (FOR CPD, NURSING SCIENCE & POSTGRADUATE PROGRAMME ONLY)

PART I : INTERNATIONAL STUDENTS ONLY

Are you holding any type of Malaysian Immigration Pass now? Yes No

If yes, please specify the pass type Social Visit Student Dependant Diplomatic MM2H

Applicable to students / former students from other institutions in Malaysia only

Institution Course Duration

PART J : ADDITIONAL INFORMATION

Have you ever been involuntarily withdrawn from any institution of higher learning? Yes No

If yes, please elaborate and submit relevant document during registration

Have you ever been convicted, or under investigation for any offence(s) in any country? Yes No

If yes, please elaborate and submit relevant document during registration

PART K : DECLARATION

I, name of application (as per NRIC/Passport) declare that the information provided by me in

Signature of applicant

Name of applicant

PART L : CHECKLIST ON DOCUMENT

Certified copy of all academic transcripts (high school, pre-university, diploma, degree and others).

Certified copy of all English proficiency test results (IELTS and/or MUET) or copy of registration slip.

* Hepatitis B screening lab report.

* Hepatitis C and HIV screening lab report (For application into Medicine and Dentistry only* Screening lab report may be submitted during interview or upon receipt of offer.

Payment for Processing Fees (please refer Part M: Instruction Sheet).

for Malaysian student only:

Certified copy of NRIC (on A4-size paper).

for International student only:

4 x passport size colour photographs.

1 x photocopy of passport (ALL PAGES including front cover and blank pages on A4-size paper).

No Objection Certificate (Applicable to Nationalities of Sub-Saharan Countries).

* For visa processing purposes. Lab report may be submitted upon receipt of offer.

/ /

years

YM

Y

connection with my application is TRUE and COMPLETE. I understand that the International Medical University (IMU) reserves the right to vary or reverse any decisionregarding admission or enrolment made on the basis of incorrect or incomplete information. I authorise the IMU to obtain further documentation pertaining to my personaland academic records from any relevant examination body and education institution where necessary.

Date of SubmissionY Y Y

Listening Reading Writing

D D M M Y

Registration Date (for Nursing Science students only) / /D M

Reading Writing Speaking

Date (mm/yyyy):

Overall Band ScoreEnglish Test Components

D M M Y Y

Y Y YD

Y

months

Hospital Name (for Nursing Science students only)Place of Work

years months

months

MUET (for Malaysian students only)

Experience

years

Speaking

b.

a.

Immigration Pass expiry date / /D

Individual Band Score

Date (mm/yyyy):

Listening

IELTS

Individual Band Score


PART M : INSTRUCTION SHEET

1.

FOR OFFICE USE ONLY

Eligibility Yes No

Signature and Name

Appointed Overseas Representative's Stamp (if applicable)

RM150

MalaysianProgramme

Medical / Dentistry

Complementary Medicine, Pharmacy, Nursing & Health Sciences

International

RM950

RM500

Y Y

APP/

2.

3.

4.

Y Y Y Y

Processed by

Date

Kindly ensure that all admission requirements are met before submitting this application. Please contact our Admission Department at 03-8656 8813 if you are unsure.

The preferred name field is required to produce your ID tag. The preferred name must match the given name in NRIC or Passport.

Example:(i) Tan Boon Huat. Preferred name could be BOON HUAT or TAN BOON HUAT. ERIC TAN is not permitted.(ii) Nurul Anisa Wahidah. Preferred name could be NURUL ANISA or ANISA WAHIDAH or ANISA. NISA is not permitted.

Processing fees (as stated below) must be enclosed and made payable to IMU EDUCATION SDN. BHD. This processing fees will be waived if you have previously appliedfor the same programme. Processing fees are NON-REFUNDABLE regardless of the outcome of the application.

Please complete ALL sections in this form in BLOCK letters. Incomplete applications may result in delay in processing of the application. You may use additional sheets ifspace provided is insufficient.

Changing or Switching options are NOT allowed after the commencement date for the Medical and Dentistry Programmes.

Interviews are part of the admission process for the Medical and Dentistry programmes and applicants are required to attend the interview as scheduled.

Please contact our Admission Department to schedule your interview once you have paid the application fee.

On the day of your interview, you are required to: a. Bring the original and photocopy of your documents (academic and extra curricular activities). b. Be dressed in formal attire.c. Be present at the IMU Admissions Department (Ground level) at least 1 hour before your scheduled interview time. Please submit this application form and all the required documents either via email or courier to:

Admissions DepartmentInternational Medical University126, Jalan Jalil Perkasa 19Bukit Jalil57000 Kuala Lumpur, MALAYSIATel: +603-8656 8813Email: [email protected]

/ /D D M M

Application No

Date received / /D D M M Y Y

RM300


PRIVACY NOTICE IMU Health Sdn Bhd and its subsidiaries (collectively referred to herein as “IMU”) are committed to protecting your personal data in accordance with the applicable laws, rules and regulations currently in force. If you are applying and/or register for a programme with the following education institutions or a student of the following education institutions, the personal data that you provide will be processed by the following entities:- No.

Education Institution

Corporate Entity

1. International Medical University

IMU Education Sdn Bhd (Company No. 237397-W)

2. International Medical College Melaka IMC Education Sdn Bhd (Company No. 431251-W)

3. International Medical College Subang Jaya IMC Education Sdn Bhd (Company No. 431251-W)

Any reference to the words “We”, “Us” and “Our” would refer to the above applicable entities. Due to the fact that the above entities are within the same group of companies and also due to the nature of our business, your personal data will be shared between the above entities including IMU Health Sdn Bhd. Please read this notice to understand how we use and protect your personal data. Collection of Personal Data When you apply and/or register for a programme, you will be required to provide certain personal data about yourself such as, name, particulars of identity document (NRIC or passport), ethnicity, gender, religion, marital status, pictures, nationality, date of birth, medical condition, particulars of family members, survey information, preference, and academic and skill information. IMU may also collect from you and your parents/guardian, credit card number or bank account details. To enable us to process your application and/or registration for a programme, we will need the information marked as mandatory. If we accept your application, you will be required to provide further information regarding your health and academic information. If you have any objection to the collection of such information, please notify us immediately. We will also be processing other personal data relating to you, such as, transcripts, examination results and mentor’s feedback. By providing the requested information, you hereby consent to us processing of your personal data. While you are not obligated to provide us with the non-mandatory data, your choice not to provide mandatory personal data may result in us being unable to provide you with the relevant services. Your image may be recorded in a form of a photograph or video recording during your studies in IMU and it may appear in advertisements, prospectus, newsletters, website and any other publications or multimedia presentations. By registering in our programmes, you agree that such image belongs to us and you waive any claim, if any, on any material where such images may appear.

The accuracy of your personal data is important. As a student of IMU, you are responsible for informing us of changes to your personal data so that the information are accurate, not misleading, complete and up-to-date. Use and Disclosure of Personal Data We use your personal data:- • For assessing your application; • For processing your application/registration for the programme; • For verification purposes; • our mentor-mentee programme; • To respond to your enquiries; • To enable us to provide you with the services or facilities which you have requested; • To contact you about the programme; • To offer and update you on our products and/or services; • For advertising and promotional purposes; and • For research and statistical purposes. Disclosure We may disclose your personal data to:- (1) our partner schools and other collaborative partners who work with us to provide the

programme; (2) licensing boards (whether in Malaysia or overseas); (3) our related, associated or affiliated entities including IMU; (4) regulatory bodies, government department or agencies such as the Ministry of Higher

Education (MOHE) and Malaysia Immigration Department (if you are a foreign student); (5) another tertiary institution if you apply to transfer your studies; (6) your scholarship or sponsorship providers; (7) another institution where you are enrolled under an official student exchange, cross-

institutional study, dual degree, shared teaching, industry or clinical experience or multi-institutional arrangement with that institution to facilitate the collaboration or arrangement;

(8) alumni association on your graduation and when you apply to join the said alumni. (9) any third party service provider, agent or contractor who have been appointed by IMU to

provide services to IMU whether in or outside Malaysia subject to sufficient security controls over the information (such as recruitment, data processing services, systems and website maintenance, media and marketing services, delivery services, audit, insurance);

(10) our auditors, lawyers, consultants and other advisors; (11) parties authorised by you; and (12) any other party to whom such disclosure is required by law or regulatory requirement or

pursuant to a Court order.

The partner schools, collaborative partners, representatives, advisor, agents and/or contractors may be located in countries other than Malaysia who may not have equivalent laws and rules regarding personal data protection. As part of the application process, we may also:- • collect personal data about you from; or • disclose such personal data to, other sources such as your college or other academic institutions you have attended to verify your information such as your examination results. Your personal data may also be disclosed to the relevant government authorities (for the purposes of licensing, registration, rating system) or where required by law or where disclosure is necessary to comply with applicable laws, legal processes or queries from governmental authorities. If we are merged or acquired by another entity, the personal data may be transferred to such entity as a part of the merger or acquisition.

Personal Data of Third Parties If you provide us with personal data of third parties such as your parents or guardians, please do ensure that you have obtained their consent and bring this Privacy Notice to their attention.

Data Security We take appropriate security measures to protect your personal data from unauthorised access, misuse, loss, alteration or destruction. Data Access If you would like to make any inquiries or complaints or request access or correction of the personal data, please contact us at:- Elaine Teh Acting Head, Admissions Department 03-2727 7566 Email: [email protected] Any request of access or correction of personal data may be subject to a fee and also to any privacy or data protection laws. You are required to complete our Personal Data Access Form in order to request access or correction of personal data. However, we reserve the right to decline to process requests which jeopardize the security and privacy of the personal data of others as well as requests which are impractical or not made in good faith. Where you elect to limit our right to process the personal data, you may contact us in writing. For avoidance of doubt, the limitation does not include processing of mandatory personal data. How to contact us If you have any question, comment, request or concern related to this Privacy Notice, or if you would like to opt out of future communications, please email to [email protected].

NOTIS PRIVASI IMU Health Sdn Bhd dan anak-anak syarikatnya (secara kolektif dirujuk di sini sebagai "IMU") berhasrat untuk melindungi data peribadi anda selaras dengan undang-undang, kaedah-kaedah dan peraturan-peraturan yang berkuatkuasa. Jika anda memohon dan/atau mendaftar untuk suatu program dengan institusi-institusi pendidikan yang berikut atau seorang pelajar institusi-institusi pendidikan berikut, data peribadi yang anda berikan akan diproses oleh entiti-entiti berikut: - No.

Institusi Pendidikan Entiti Korporat

1. Universiti Perubatan Antarabangsa IMU Education Sdn Bhd (No Syarikat. 237397-W)

2. Kolej Perubatan Antarabangsa Melaka IMC Education Sdn Bhd (No Syarikat. 431251-W)

3. Kolej Perubatan Antarabangsa Subang Jaya IMC Education Sdn Bhd (No Syarikat. 431251-W)

Apa-apa rujukan kepada perkataan "Kami" akan merujuk kepada entiti di atas yang berkenaan. Oleh kerana entiti-entiti di atas adalah dalam kumpulan syarikat yang sama dan juga disebabkan oleh sifat perniagaan kami, data peribadi anda akan dikongsi di antara entiti-entiti di atas termasuk IMU Health Sdn Bhd. Sila baca notis ini untuk memahami bagaimana kami menggunakan dan melindungi data peribadi anda. Pengumpulan Data Peribadi Apabila anda memohon dan/atau mendaftar untuk suatu program, anda perlu membekalkan data peribadi tertentu mengenai diri anda seperti nama, butir-butir dokumen pengenalan (KP atau pasport), bangsa, jantina, agama, status perkahwinan, gambar, kewarganegaraan, tarikh lahir, keadaan kesihatan, butir-butir ahli keluarga, maklumat kajian, pilihan, dan maklumat akademik dan kemahiran. IMU juga mungkin mengumpul daripada anda dan ibu bapa/penjaga anda, nombor kad kredit atau butiran akaun bank. Untuk membolehkan kami memproses permohonan dan/atau pendaftaran anda untuk suatu program, kami memerlukan maklumat yang ditandakan sebagai wajib. Jika kami meluluskan permohonan anda, anda dikehendaki untuk memberi maklumat lanjut mengenai maklumat kesihatan dan akademik anda. Jika anda mempunyai apa-apa bantahan kepada pengumpulan maklumat tersebut, sila maklumkan kami dengan segera. Kami juga akan memproses data lain peribadi berkaitan dengan anda, seperti, transkrip-transkrip, keputusan peperiksaan dan maklum balas mentor. Dengan memberikan maklumat yang diminta, anda dengan ini bersetuju dengan pemprosesan data peribadi anda oleh kami. Walaupun anda tidak diwajibkan untuk menyediakan kami dengan data bukan mandatori, pilihan anda untuk tidak memberikan data peribadi mandatori mungkin menyebabkan kami tidak dapat untuk menyediakan anda dengan perkhidmatan yang berkaitan. Imej anda boleh direkodkan dalam bentuk gambar atau video semasa pengajian anda di IMU dan ia boleh muncul dalam iklan, prospektus , surat berita, laman web dan mana-mana penerbitan atau persembahan multimedia lain. Dengan mendaftar dalam program-program kami, anda bersetuju

bahawa imej itu adalah milik kami dan anda mengetepikan apa-apa tuntutan, jika ada, pada apa-apa bahan di mana imej itu boleh muncul. Ketepatan data peribadi anda adalah penting. Sebagai pelajar IMU, anda bertanggungjawab untuk memaklumkan kami tentang perubahan kepada data peribadi anda supaya maklumat tersebut adalah tepat, tidak mengelirukan, lengkap dan terkini. Penggunaan dan Pendedahan Data Peribadi Kami menggunakan data peribadi anda: - • Untuk menilai permohonan anda; • Untuk memproses permohonan/pendaftaran anda untuk program ini; • Untuk tujuan pengesahan; • program mentor-mentee kami; • Untuk membalas pertanyaan anda; • Bagi membolehkan kami untuk menyediakan anda dengan perkhidmatan atau kemudahan yang

anda minta; • Untuk menghubungi anda mengenai program ini; • Untuk menawarkan dan mengemaskini anda dengan produk dan/atau perkhidmatan kami; • Untuk tujuan-tujuan pengiklanan dan promosi; dan • Bagi tujuan-tujuan penyelidikan dan statistik. Pendedahan Kami mungkin mendedahkan data peribadi anda kepada: - (1) sekolah-sekolah sekutu dan rakan-rakan kerjasama lain yang bekerja dengan kami untuk

menyediakan program; (2) Badan-badan perlesenan (sama ada di dalam atau luar Malaysia) (3) entiti-entiti yang berkaitan, bersekutu atau bergabungan dengan kami termasuk IMU ; (4) Badan-badan kawal selia, jabatan-jabatan atau agensi-agensi kerajaan seperti Kementerian

Pengajian Tinggi (KPT) dan Jabatan Imigresen Malaysia (jika anda seorang pelajar asing); (5) institusi pengajian tinggi yang lain jika anda memohon untuk memindahkan kajian anda; (6) pembekal-pembekal biasiswa atau penaja anda; (7) institusi yang lain di mana anda mendaftar di bawah pertukaran pelajar rasmi, kajian silang

institusi, ijazah dual, pengajaran bersama, pengalaman industri atau klinikal atau susunan multi-institusi dengan institusi tersebut untuk memudahkan kerjasama atau susunan;

(8) persatuan alumni selepas anda tamat pengajian dan apabila anda memohon untuk menyertai persatuan alumni tersebut.

(9) apa-apa pembekal perkhidmatan, ejen atau kontraktor pihak ketiga yang dilantik oleh IMU untuk menyediakan perkhidmatan kepada IMU sama ada di dalam atau di luar Malaysia tertakluk kepada kawalan keselamatan yang mencukupi ke atas maklumat (seperti perekrutan, perkhidmatan pemprosesan data, penyelenggaraan sistem dan laman web, perkhidmatan media dan pemasaran, perkhidmatan penghantaran, audit , insurans);

(10) juruaudit-juruaudit, peguam-peguam, perunding-perunding dan penasihat-penasihat lain kami; (11) pihak-pihak yang diberi kuasa oleh anda; dan (12) mana-mana pihak lain yang kepadanya penzahiran sedemikian dikehendaki oleh undang-

undang atau keperluan peraturan atau menurut suatu perintah Mahkamah. Sekolah-sekolah rakan kongsi, rakan-rakan kongsi kerjasama, wakil-wakil, penasihat-penasihat, ejen-ejen dan/atau kontraktor-kontraktor mungkin terletak di negara-negara selain Malaysia yang mungkin tidak mempunyai undang-undang yang setaraf dan peraturan mengenai perlindungan data peribadi. Sebagai sebahagian daripada proses permohonan tersebut, kami juga mungkin: - • mengumpul data peribadi mengenai anda dari ; atau • mendedahkan data peribadi tersebut kepada, sumber-sumber lain seperti kolej atau institusi akademik lain yang anda pernah hadir untuk mengesahkan maklumat anda seperti keputusan-keputusan peperiksaan anda.

Maklumat peribadi anda juga boleh didedahkan kepada pihak-pihak berkuasa kerajaan yang berkaitan (untuk tujuan-tujuan pelesenan, pendaftaran, sistem penarafan) atau dikehendaki oleh undang-undang atau jika pendedahan adalah diperlukan untuk mematuhi undang-undang, proses undang-undang atau pertanyaan daripada pihak-pihak berkuasa. Jika kami bergabung atau diperolehi oleh entiti lain, maklumat peribadi mungkin dipindahkan kepada entiti tersebut sebagai sebahagian daripada penggabungan atau pengambilalihan. Data Peribadi Pihak-pihak Ketiga Jika anda memberikan kami data peribadi pihak ketiga seperti ibu bapa atau penjaga anda, sila pastikan bahawa anda telah mendapatkan persetujuan mereka dan membawa Notis Privasi ini kepada perhatian mereka. Keselamatan Data Kami mengambil langkah-langkah keselamatan yang sewajarnya untuk melindungi data peribadi anda daripada akses yang tidak dibenarkan, penyalahgunaan, kehilangan, pengubahan atau pemusnahan. Akses Data Jika anda ingin membuat sebarang pertanyaan atau aduan atau akses permintaan atau pembetulan data peribadi, sila hubungi kami di : - Elaine Teh Acting Head, Admissions Department 03-2727 7566 Email: [email protected] Apa-apa permintaan akses atau pembetulan data peribadi mungkin dikenakan bayaran dan juga tertakluk kepada mana-mana undang-undang privasi atau perlindungan data. Anda dikehendaki melengkapkan Borang Akses Data Peribadi kami untuk meminta akses atau pembetulan data peribadi. Walau bagaimanapun, kami berhak untuk menolak permintaan proses yang menjejaskan keselamatan dan privasi data peribadi orang lain dan juga permintaan yang tidak praktikal atau tidak dibuat dengan suci hati. Di mana anda memilih untuk menghadkan hak kami untuk memproses data peribadi, anda boleh menghubungi kami secara bertulis. Untuk mengelakkan keraguan, pilihan tersebut tidak termasuk pemprosesan data peribadi mandatori. Bagaimana untuk menghubungi kami Jika anda mempunyai apa-apa soalan, komen, permintaan atau kebimbangan berkaitan dengan Notis Privasi ini, atau jika anda ingin untuk memilih keluar daripada komunikasi masa depan, sila e-mel kepada [email protected].

Documents

Application Form Ver 8.2013 (Updated 2013-12-09 PDPA)