Cyberjaya University College of Medical Sciences

	Online Application Form

Cyberjaya University College of Medical Sciences Online Application Form
Note: * - compulsory fields.

Session and Year
Select the Session and Year you plan to enroll.
Session*		Year*

Programme of Choice
Select your preferred programme. You must select a First Choice.
First Choice*
Second Choice
Third Choice

Personal Details
Name*
Identity Card (IC)*	(Format: 123456-12-1234)
Place of issue of IC*
Citizenship/Nationality*
Race*
Religion*
Date of Birth*	Date Month Year (Ex: 1990)
Country of Birth*
Gender*
Marital Status*
Handphone*	(Numbers only)
Email*

Postal Address
Address (Line 1)*
Address (Line 2)
Address (Line 3)
Postcode*	(5 digit number only, Ex: 50450)
State*
Telephone* (at this address)	(Numbers only)

Permanent Address
Address (Line 1)*
Address (Line 2)
Address (Line 3)
Postcode*	(5 digit number only, Ex: 50450)
State*
Telephone* (at this address)	(Numbers only)

Parent/Guardian Details
Name*
Identity Card*
Citizenship/Nationality*
Occupation*
Monthly Income (RM)*	(Numbers only)
No.of Dependant
Address (Line 1)*
Address (Line 2)
Address (Line 3)
Postcode*	(5 digit number only, Ex: 50450)
State*
Handphone*	(Numbers only)
Telephone (Office)*	(Numbers only)

Emergency Contact
Name*
Relation*
Address (Line 1)*
Address (Line 2)
Address (Line 3)
Postcode*	(5 digit number only, Ex: 50450)
State*
Telephone*	(Numbers only)

Academic Qualifications

SPM/SPMV/'O'-Levels

School*

Year*

(Ex: 1990)

Subjects	Grades	Subjects	Grades
Bahasa Melayu		Biology
English		Physics
Mathematics		Chemistry
Science		Additional Mathematics
History		EST
Islamic Education		Accounts Principle
Moral Education

Other subjects SPM/SPMV/'O'-Levels	Grades

STPM
(Grading scheme for STPM starting 2003: Principle passes are A+, A, A-, B+, B, B-, C+, C)

School

Year

(Ex: 1990)

Principle

Subjects	Grades	Subjects	Grades
Bahasa Melayu		Mathematics S
English		Mathematics T
Mathematics Advance T		Physics
Chemistry		Biology
General Study

Universities/College/Matriculation Qualification

University/College	Highest Qualification	Programme	Performance

Working Experience

Please State the name of company, position, duration and job description (if applicable)

Medical History

Is there any medical condition of the applicant 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 on the basis of incomplete information. I also agree to abide by all CUCMS's rules and regulations.
Put a check in the box (by clicking on it) to accept this declaration.

CYBERJAYA UNIVERSITY COLLEGE OF MEDICAL SCIENCES
Unit No.2 Street Mall 2, 63000 Cyberjaya,
Selangor Darul Ehsan, Malaysia. Tel : 603 8319 1010 Fax : 603 8319 1100