ADMISSION INFORMATION

INSTRUCTIONS
All information should be fill in CAPITAL LETTERS
Please tick ( ) where applicable

PROGRAMME
BACHELOR OF MEDICINE AND BACHELOR OF SURGERY (M.B.B.S)
(JPT/BPP(U)1000-801/65/JLD.2(4))
BACHELOR OF PHARMACY (HONS)
(JPT/BPP(U)1000-801/65/JLD.I(36))
PERSONAL PARTICULARS
FULL NAME
(as in NRIC/Passport)
NRIC NO.
(MALAYSIAN)

NATIONALITY

PASSPORT NO.
(INTERNATIONAL)

EXPIRY DATE

HOME ADDRESS

POSTCODE

STATE/COUNTRY

CONTACT NO.
(HOME)

HANDPHONE NO.

GENDER

MARITIAL STATUS

RACE

RELIGION

Affix passport size

photo

AGE

DATE OF BIRTH

EMAIL
PARENTS / GUARDIAN INFORMATION
FATHER
TITLE
(PLEASE SPECIFY : Tan Sri/Datuk/Dato'/Dr/Mr/etc)
NAME
(as in NRIC/Passport)
HOME ADDRESS

CONTACT NO.
(HOME)

HANDPHONE NO.

CONTACT NO.
(OFFICE)

FAX NO.

COMPANY
OCCUPATION

ANNUAL INCOME

EDUCATION
(HIGHEST LEVEL)
EMAIL ADDRESS
MOTHER
TITLE
(PLEASE SPECIFY : Tan Sri/Datuk/Dato'/Dr/Mdm/etc)
NAME
(as in NRIC/Passport)
HOME ADDRESS

CONTACT NO.

HANDPHONE NO.

(HOME)
CONTACT NO.
(OFFICE)

FAX NO.

COMPANY
OCCUPATION

ANNUAL INCOME

EDUCATION
(HIGHEST LEVEL)
EMAIL ADDRESS
GUARDIAN
TITLE
(PLEASE SPECIFY : Tan Sri/Datuk/Dato'/Dr/Mr/Mdm/etc)
NAME
(as in NRIC/Passport)
HOME ADDRESS

CONTACT NO.
(HOME)

HANDPHONE NO.

CONTACT NO.
(OFFICE)

FAX NO.

COMPANY
OCCUPATION

ANNUAL INCOME

EDUCATION
(HIGHEST LEVEL)
EMAIL ADDRESS
ADDITIONAL INFORMATION
PARENT'S MARITIAL STATUS
DIVORCED
MARRIED
SEPERATED

DECEASED
(MOTHER/FATHER)

ACADEMIC QUALIFICATION & RECORD

EDUCATION INSTITUTIONS ATTENDED
(Please certified true copies of certificates and academic transcripts)
FROM (MM/YY)

TO (MM/YY)

QUALIFICATION

INSTITUITION
/UNIVERSITY

SPM RESULT OR O'LEVEL RESULT

SPM RESULTS OR O'LEVEL RESULT
YEAR

AGGREGATE

SUBJECT & GRADE

BAHASA MELAYU

BIOLOGY

ENGLISH

PHYSICS

MATHEMATICS

CHEMISTRY

ADDITIONAL
MATHEMATICS

OTHERS

FOUNDATION/MATRICULATION/ASASI SAINS/SAM/CPU/AUSMAT/STPM /A'LEVEL RESULT

CGPA /
AGGREGATE
BIOLOGY
PHYSICS
CHEMISTRY
MATHEMATICS

ADDITIONAL
MATHEMATICS

ENGLISH LANGUAGE ACHIEVEMENT

TOEFL

MUET

IELTS

OTHERS

NAME OF INSTITUITION
SCORE / GRADE
SCHOLARSHIPS, AWARDS OR SPECIAL ACADEMIC ACHIEVEMENTS
DATE (MM/YY)

ACHIEVEMENTS

EXTRA CURRICULAR ACTIVITIES

ACTIVITY

LEVEL OF INVOLVEMENT

MEDICAL DISCLOSURE
Is there any medical condition of the application that requires the attention of CUCMS? If yes, please
specify

DECLARATION BY THE APPLICANT

I declare that the information provided with this application are true and correct. I understand that
CUCMS reserves the right to vary or reverse any decision regarding admission or enrollment made
on the incomplete information. I also agree to abide by all CUCMS's rules and regulations.

Signature of Applicant

Date
ENCLOSURES (Required documents )
The following document must be submitted together with application form :
a) Certified true copy of SPM/O'Level certificate and
b) Certified true copy of NRIC
c) Passport size photo (1 pc)
d) Parent's / Guardian's EA form - Annual income statement / Salary slip
e) Crossed cheque/Bank draft/Postal order
Payable to
IN-FUSION EDUCATION SDN BHD
Account no
5144-9520-5474
Ammount
RM 150.00 (Local student)
RM 250 (International student)

Upon completion, this form should be returned to (post/by hand) :

ADMISSION UNIT
CYBERJAYA UNIVERSITY COLLEGE OF MEDICAL SCIENCES (MAIN CAMPUS)
NO. 3410 JALAN TEKNOKRAT 3
CYBER 4
63000 CYBERJAYA
SELANGOR DARUL EHSAN
TOLL FREE LINE
GENERAL LINE
ADMISSION UNIT
FAX
WEBSITE

1-800-88-28267
+603-8313 7000
+603-8313 7091/7114/7020
+603-8313 7090/7001
www.cybermed.edu.my