FORM NO: SDNHS/ADM/026

APPLICATION FORM
For office use only:

Sime Darby Nursing and Health Sciences College

(B4P8025) Programme: Centre Point Business Park, Jalan Tanjong Keramat 26/35, Seksyen 26, 40400 Shah Alam, Selangor Darul Ehsan, Malaysia T: 603-5191 2121/1346, 603-5122 0790/4028; F: 603-51911357 Sequence No: E: simedarbycollege.student@simedarby.com W: www.simedarbycollege.edu.my 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. E.g Copy of SPM result 4 A crossed cheque/money order/bank draft for the first payment made in favour of Sime Darby Healthcare Educational Services Sdn. Bhd. 5 *Please tick where applicable. ()

PERSONAL DETAILS
Name: IC / Passport No: Sex*: Race: Nationality: Correspondence Address : Marital Status*: Religion: Email:

Postcode : Permanent Address :

State:

Country:

Poscode : Telephone No:

State: Mobile No:

Country:

Name of Parent/Guardian/Husband: Relationship: Correspondence Address:

Postcode : Telephone No:

State: Mobile No:

Country:

Please indicate your choice of program with a tick () in the boxes provided below: Diploma In Nursing JPT/BPP(K)1000-600/B202JLD2(42)(R/723/4/0034)(A7589)04/17 Diploma In Nursing (Assistant Nurse Conversion Program) JPT/BPP(K)1000-600B202JLD2(42)(R/723/4/0038)(A7590)04/17 Diploma In Medical Laboratory Technology KPT(JPS)600-03/1368(30)(KA8915)(A8915)08/13 Diploma In Physiotherapy JPT/BPP(K)1000-600/B202(53)(KA11163)(PA11163)07/15 Diploma In Medical Assistant JPT/BPP(K)1000-600/B202JLD2(43)(N/723/4/0039)(PA0966)04/17 Diploma in Healthcare Service JPT/BPP(K)1000-600(N/720/4/0032)(PA2037)12/17 Postgraduate Certificate in Teaching Methodology JPT/BPP(K)1000-600/B202(29)(KA 10167)(A(10167)01/15 Professional Certificate in Critical Care Nursing JPT/BPP(K)1000-600/B202(52)(KA 10377)(A 10377)07/15 Professional Certificate in Perioperative Nursing JPT/BPP(K)1000-600/B202(52)(KA 10378)(PA 10378)07/15 Foundation in Sciences JPT/BPP(K)1000-600/B202JLD2(3)(N/010/3/0013)(FA 0093)12/16 English Language Program Year:
Sources: Sime Darby Nursing and Health Sciences College, dated 31st January 2013 1

PROGRAMME PREFERENCE

FORM NO: SDNHSC/ADM/026

HOSTEL PREFERENCE
Required Not Required

SOURCE OF INFORMATION
How do you know about us?

(Please specify)

CONDITIONS OF ENROLMENT / APPLICATION

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. 2. Enrolment will be subject to the student clearing his/ her medical examination and full payment of the registration fees. 3. 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. alternatively, you may bank in the registration fee to our company account: CIMB Account No. 1224 00106 90058 and fax to us the bank slip at 03-5191 1357. 4. Pre-Registration fee / registration fee is non refundable nor transferable. 5. 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 ofthe Programme. a) If a student withdraws before commencement of the semester, an amount not exceeding 70% of all fees (not inclusive of the pre-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 pre-registration and cocurricular 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. e) 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.

DECLARATION
I ____________________________________________________ declare all the information provided in this form is accurate. I acknowledge that Sime Darby Nursing and Health Sciences College reserves the right to reverse any decision made regarding admission on the basis of incorrect or incomplete information. I agree to:i) Abide by the conditions of enrolment / application ii) Make all necessary payments due to the College within the specified dates in respect of the programme enrolled. Applicant's Name and Signature : _______________________ Date:
Day

/
Month

/
Year

FOR OFFICE USE ONLY

Enrollment Type: Finance: q q Conditional Offer Self Paying q Full Offer q Sponsored: ________________________
(Please specify)

q Eligible to apply for PTPTN

Enrolled by:______________________________ Payment Pre-registration Fee Received Amount Received: ___________________________ Payment Mode: qBank draft qCash qCheque

Date:________________

Outstanding Balance :________________ qBank-in No: _______________ Date:______________

Received by:______________________________ Remark:

Sources: Sime Darby Nursing and Health Sciences College, dated 31st January 2013