FORM NO: SDNHS/ADM/026
REGISTRATION FORM
For office use only:
Sime Darby Nursing and Health Sciences College (B4P8025)
Centre Point Business Park, No. 5, Lot 728, Jalan Tanjong Keramat 26/35, Seksyen 26, 40400 Shah Alam, Selangor Darul Ehsan, Malaysia.
Programme: Sequence No : Student No:
T: 603-5191 2121/1346/3746 F: 603-5191 1357
E: [Link]@[Link]
Instructions to complete the Form: 1. Please write in BLOCK letters (in blue or black ink only). 2. Attach a certified true copy of actual results. 3. Attach a photocopy of IC and other supporting documents if necessary. 4. Kindly affix your recent passport size photograph. 5. A crossed cheque/money order/bank draft for the first payment made in favour of Sime Darby Healthcare Educational Services Sdn. Bhd. 6. *Please tick where applicable.
A. PERSONAL DETAILS
First Name: I. C No: Date of Birth: :
Day
Last Name: Place of Birth:
/
Month
Please affix a recent passport size photograph
/
Year
Age: Marital Status: Religion:
Sex: Race:
Male
Female
Married
Single
here.
Nationality: Correspondence Address: Postcode: Permanent Address: Postcode: Telephone No.: Mobile-phone No.: Name of Parent/Guardian: If Guardian, state the relationship: Correspondence Address: Postcode: Telephone No.: Mobile-phone No.: In case of emergency contact the following person: Name: Correspondence Address: Postcode: Telephone No.: Mobile-phone No.: Fax No.: E-mail: State: Relationship: Fax No.: E-mail: State: Fax No.: E-mail: State: State:
Source: Sime Darby Nursing and Health Sciences College, dated 9 June 2010.
B. PROGRAMME PREFERENCE
Please indicate your choice of program with a tick in the boxes provided below:
Diploma in Nursing KPT/JPS(A7589)/04/12 Diploma in Nursing (Assistant Nurse Conversion Program) KPT/JPS(A7590)/04/12 Diploma in Medical Laboratory Technology KPT/JPS(KA8915)/08/13 Diploma in Physiotherapy JPT/BPP(KA11163)/07/15 Postgraduate Certificate in Teaching Methodology JPT/BPP(KA10167)/01/15 Post Graduate Certificate in Critical Care Nursing JPT/BPP(KA10377)/07/15 Post Graduate Certificate in Peri-Operative Nursing JPT/BPP(KA10378)/07/15 English Language Programme
Intake:
January March
April
July
September
Year:
C. EDUCATIONAL BACKGROUND
School/ College/ University Attended (In Chronological Order)
No. 1. 2. 3. 4. Name of Previous Institution Examination Year Achievement
D. ENGLISH QUALIFICATIONS
SPM - English IELTS TOEFL MUET Others
Grade/ Proficiency Obtained (Please specify):
(Please specify)
E. ACCOMMODATION (if required):
Please tick where applicable
Hostel Required Hostel Not Required
Note: Hostel Accommodation is limited and outstation students will be given priority.
F. PRESENT EMPLOYMENT (IF ANY)
Occupation : Company Name : Correspondence Address: Postcode: Telephone No.: Fax No.: State: Year Joined:
Source: Sime Darby Nursing and Health Sciences College, dated 9 June 2010.
G. CONDITIONS OF ENROLMENT
1. Full s e t t l e m e n t o f f i r s t s e m e s t e r / t e r m f e e s i s r e q u i r e d u p o n registration or one week before the intake date as specified in the Fee Schedule. Enrolment will be subject to the student clearing his/ her medical examination. All payments are to be made in the form of cash (RM), bank draft or crossed cheque made payable to Sime Darby Healthcare Educational Services Sdn. Bhd. Registration fee is non refundable nor transferable. Refund: Fees paid are neither refundable nor transferable except in circumstances set out below and provided that a request in writing for such a refund is made to the Head of Programme. a) If a student withdraws before the commencement of the semester, an amount not exceeding 70% of all fees (not inclusive of the registration and co-curricular fee) is refundable. b) If a s t u d e n t w i t h d r a w s within the second week of the semester, an amount not exceeding 50% of all fees (not inclusive of the registration and co-curricular fee) is refundable. c) There will be no refund if the student withdraws after the second week of the semester. d) However, if a student is asked to leave the programme because he/she is deemed unfit after the medical examination, he/she is eligible for a full refund of all fees paid. If a student is required to serve in National Service because his/her request for deferral was rejected, he/she is eligible for a full refund of all fees paid. 6. NoRefund: There shall be no refund if a student is expelled from the College due to academic misconduct or disciplinary behaviour. 7. PaymentofRefund: All refund payments shall be made to the parent/guardian as specified in the Registration Form or the sponsor (if applicable). 8. LatePaymentFine All fees due for the programme must be paid in full one week before the commencement of the semester. Under special circumstances, and where requested in writing to the Registrar, the student may be allowed to settle all payments in full, before the end of the second week of the semester. An administrative fee of RM 50.00 per week will apply to any late payments or if payment is not received by the end of the second week of the semester. 9. The College reserves the right to review the status of the student and take the necessary actions if payment is not received by the end of the fourth week of the semester. 10. The College reserves the right to use your personal information in order to carry out its responsibilities in your personal and/ or academic interest as a student. The scope of usage of this information may include the publishing of examination results, the award of a prize or scholarship or otherwise. e)
2. 3.
4. 5.
Students Copy
G. CONDITIONS OF ENROLMENT
1. Full settlement of first semester/ term fees is required upon registration or one week before the intake date as specified in the Fee Schedule. Enrolment will be subject to the student clearing his/ her medical examination. All payments are to be made in the form of cash (RM), bank draft or crossed cheque made payable to Sime Darby Healthcare Educational Services Sdn. Bhd. Registration fee is non refundable nor transferable. Refund: Fees paid are neither refundable nor transferable except in circumstances set out below and provided that a request in writing for such a refund is made to the Head of Programme. a) If a student withdraws before the commencement of the semester, an amount not exceeding 70% of all fees (not inclusive of the registration and co-curricular fee) is refundable. b) If a student withdraws within the second week of the semester, an amount not exceeding 50% of all fees (not inclusive of the registration and co-curricular fee) is refundable. c) There will be no refund if the student withdraws after the second week of the semester. d) However, if a student is asked to leave the programme because he/she is deemed unfit after the medical examination, he/she is eligible for a full refund of all fees paid. If a student is required to serve in National Service because his/her request for deferral was rejected, he/she is eligible for a full refund of all fees paid. 6. NoRefund: There shall be no refund if a student is expelled from the College due to academic misconduct or disciplinary behaviour. 7. PaymentofRefund: All refund payments shall be made to the parent/guardian as specified in the Registration Form or the sponsor (if applicable). 8. LatePaymentFine All fees due for the programme must be paid in full one week before the commencement of the semester. Under special circumstances, and where requested in writing to the Head of Programme, the student may be allowed to settle all payments in full, before the end of the second week of the semester. An administrative fee of RM 50.00 per week will apply to any late payments or if payment is not received by the end of the second week of the semester. 9. The College reserves the right to review the status of the student and take the necessary actions if payment is not received by the end of the fourth week of the semester. 10. The College reserves the right to use your personal information in order to carry out its responsibilities in your personal and/ or academic interest as a student. The scope of usage of this information may include the publishing of examination results, the award of a prize or scholarship or otherwise. e)
2. 3. 4. 5.
Source: Sime Darby Nursing and Health Sciences College, dated 9 June 2010.
H. DECLAR ATION
I _ declare that all information provided in this form is accurate. I acknowledge that Sime Darby College reserves the right to vary or reserve any decision regarding admission made on the basis of incorrect or incomplete information. I agree to:i) ii) iii ) Abide by the Colleges Policies, Rules and Regulations at all times. Make all necessary payments due to the College within the specified dates in respect of the programme enrolled. Attend all scheduled classes and practical sessions unless prior approval has been obtained from the management. Date: /
Day Month
Applicants Name and Signature : ____________________________
/
Year
FOR OFFICE USE ONLY
Enrolment Type:
Conditional Offer Self Paying
Full Offer Sponsored: Date: (Please specify)
Finance: Enrolled by:
PaymentReceived Amount Received: Payment Mode: Bank draft Received by: Outstanding Balance:
Cheque
Cash Bank-in
No: Date:
Remark:
Students Copy
H. DECLAR ATION
I _ declare that all information provided in this form is accurate.
I acknowledge that Sime Darby College reserves the right to vary or reserve any decision regarding admission made on the basis of incorrect or incomplete information. I agree to:iv) v) vi) Abide by the Colleges Policies, Rules and Regulations at all times. Make all necessary payments due to the College within the specified dates in respect of the programme enrolled. Attend all scheduled classes and practical sessions unless prior approval has been obtained from the management. Date:
Day
Applicants Signature : ____________________________
/
Month
/
Year
Source: Sime Darby Nursing and Health Sciences College, dated 9 June 2010.