APPLICATION FORM GRADUATE CAREER ACCELERATED PROGRAM (GCAP)

Terms & Conditions: 1) Nationality - Malaysians 2) 21 years old and above 3) IPT Graduates 4) Fresh graduates or unemployed graduates 5) CGPA : Degree 2.3 3.00 A. PERSONAL INFORMATION Please fill in all required fields in this application: Applicants Name : A A L B I D A U A L D H I I Y S A H N A A M B I N T I

(passport size photo)

I/C Number (new) :

(Please attach together with a copy of I/C)

Gender : Male Female X

8 8 0 8 1 7 - 1 1 - 5 4 4 2 Mobile Number : 0 1 7 9 0 6 4 0 5 2

Phone Number (Home) : 6 Age : 0 9 6 2 4 4 4 7 8

Date of Birth : 1 7 / 0 8 / 1 9 8 8

years old

Marital Status : Married E-mail Address : a l i a a . h i s h a m @ g Single X

Race : Malay/Chinese/Indian/Others (please

specify) ________________________________

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Permanent Address : L o t 1 9 0 5 , , L r g . G a g a k , e K g . D u r i a n u .

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Correspondence Address : L o t . 1 9 0 5 , i a n r e L o r o n g G a g a k ,

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2 0 0 5 0 e n g g a n u .

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B. ACADEMIC INFORMATION Courses completed :Degree/Master

Field of study : Bachelor of Applied Science in Industrial (hons.) Chemistry Institution : Universiti Malaysia Pahang CGPA : 2.89/4.00 Year of Completion : 2012

C. BANK ACCOUNT DETAILS Please state your active bank account number (allowance purpose):

*Bank : CIMB
(Please attach together a copy of passbook front page of Maybank, Bank Islam, CIMB)

Account Number :

D. EMERGENCY CONTACT Name : A b i a h b i n t i E m b o n g

Relationship : A u n t y

Contact Number : 0 1 3 2 5 7 8 0 1 0

Address : N o . S S e k s e l 5 0 , y e n o r J a l , a n K a r o m , S a 1 3 / 2 0 a m ,

1 3

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E. DECLARATION OF APPLICATION I hereby declare and certify that all the information given are true, accurate and complete. Applicants Signature: . Date: 29 October 2012