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PANDUAN PENDAFTARAN PELAJAR BAHARU PASCASISWAZAH

UMS/PPPS/02

STUDENT MEDICAL EXAMINATION FORM

PERSONAL INFORMATION
* TO BE COMPLETED BY THE STUDENT

Name (Capital Letter) :

Passport / ID No. :

Offered to Faculty :

Programme of Study :

Permanent Address :

Home Telephone No. : Mobile No. :

Gender : Male Female Race :

Religion : Birth of Date :

Place of Birth : Age :
(as stated in Birth Cert.)

FAMILY INFORMATION
* TO BE COMPLETED BY THE STUDENT
Father/Guardian’s Name :
(Capital Letter)

Passport / ID No. : Occupation :

Postal Address :

Telephone No. :

Name of Next of Kin :

Occupation : Relationship :

Postal Address :

Telephone No. :

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