Admission Form – Regent College

1. Personal Information

I am a:

Malaysian StudentNon-Malaysian Student

First Name:

Last Name/Surname:

Date of Birth:

Identity Card No:

Gender:

MaleFemale

Mobile No:

Email:

2. Permanent Address

Address:

City/Town:

Post Code:

State:

Country:

3. Parents's/Guardian's Details

Title

MrMsOthers(please specify)

a) Name:

Relationship:

Nationality:

MalaysianNon-Malaysian(please specify)

Address:

City/Town:

Post Code:

State:

Country:

E-mail Address:

Telephone:

Contact No:

Occupation:

Company:

Title

MrMsOthers(please specify)

b) Name:

Relationship:

Nationality:

MalaysianNon-Malaysian(please specify)

Address:

City/Town:

Post Code:

State:

Country:

E-mail Address:

Telephone:

Contact No:

Occupation:

Company:

4. Academic Qualification

Name of the institution:

Type of Qualitifcation:

Date/Year Started:

Date Awarded:

5. Extra -Curricular Activity

Name of the institution:

Type of Qualitifcation:

Date/Year Started:

Date Awarded:

6. Special Circumstances

Do you have any disability, impairment or long-term medical condtion
which may affect your studies?

YesNo

If you do, please provide extra information so that Regent's College can
assist you during your study here.

7. Work Experience (Applicable to postgraduate applicant)

Company:

Position:

Contact No:

Working Experience (Year):

8. Programme Preferred

Programme Name:

9. Declaration & Agreement by Applicant

The college collects information about its various academic, administrative, health and safety reasons. The information is processed in accordance with the Malaysian Personal Data (PDP) Act 2010 and is disclosed to third parties only with the individual's consent or to meet statutory obligations. The information provided on this application will be stored electronically and used for administrative purposes only.

10. Verification

I allow Regent College Group to contact me (your details will not be given to any third party) I agree to Regent College Group's Terms & Conditions and Privacy Policy