Revision No

Revision Date
Reference No

: 2
: 1 February 2010
: IIUM/ 215/12/ 10/1/ 7

INTERNATIONAL STUDENTS DIVISION

Application to Stay Off Campus
1. Name: ______________________________________________________
2. Passport no.: _______________________3. Matric no.: _______________
4. Gender:

Male

Female

5. Kulliyyah: _________________________6. Mahallah: ________________

Please attach
recent
passport size
photograph
here
(nonreturnable)

7. Nationality: ________________________8. E-mail Address______________________

9. Address while Staying Off Campus: __________________________________________
_________________________________________________________________________
10. Telephone no.: ____________________ (House) _____________________(H/phone)

11. Reason(s): (Please tick [] in appropriate boxes)

Married
To
stay with parent(s)/guardian(s)

Others (please specify) ___________________________________

12. Details of a person to stay with:

a) Name: _____________________________Relationship: _________________________
b) Name: _____________________________Relationship: _________________________
c) Name: _____________________________Relationship: _________________________

Revision No
Revision Date
Reference No

: 2
: 1 February 2010
: IIUM/ 215/12/ 10/1/ 7

13. The following documents to be submitted to the International Students Division:

Please tick submitted documents []
a) For married students:
Photocopy of spouse passport
Marriage certificate
Photocopy of matric card
b) For students staying with parent(s)/guardian(s):
Photocopy of parent(s)/guardian(s) passport
Letter from parent(s)/guardian(s) allowing to stay off campus
To fill up appendix A, B and C form of this application form
Photocopy of agreement between tenants and the owner of the house
Photocopy of matric card
c) For other reasons:
To fill up appendix A, B and C form of this application form
Photocopy of housemates valid international passport(front page with
picture and valid visa only) (as for Malaysian housemate, the photocopy
of identity card is required)
Photocopy of agreement between tenants and the owner of the house.
Photocopy of matric card

_________________________
Applicants Signature

_______________
Date

_________________________________________________________________
For office use only
Recommendation

Recommended

Not Recommended
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Revision No
Revision Date
Reference No

______________________________
Assistant Directors & Official Stamp

: 2
: 1 February 2010
: IIUM/ 215/12/ 10/1/ 7

_______________
Date

Appendix A
To: Officer In-charge of the International Students Division
DETAILS OF HOUSEMATES
Dear Sir,
During my staying off campus at (please write your full address _____________________
_________________________________________________________________________
_____________________________________________________________, the following
names will be my housemates. I enclosed herewith their details for your reference (please
refer to attachments for photocopy of the passport):
HOUSEMATE (1)
1) Name
2) Passport/identity card no.
3) Matric Card (for IIUM student)
3) Nationality
4) University/Institution
5) Faculty/Kulliyyah
6) Telephone/hand phone no.
7) E-mail address
8) Signature

: ______________________________________________________
: ______________________________________________________
: ______________________________________________________
: ______________________________________________________
: ______________________________________________________
: ______________________________________________________
:______________________________________________________
: ______________________________________________________
: ______________________________________________________

HOUSEMATE (2)
1) Name
2) Passport/identity card no.
3) Matric Card (for IIUM student)
3) Nationality
4) University/Institution
5) Faculty/Kulliyyah
6) Telephone/Hand phone no.
7) E-mail address
8) Signature

: ______________________________________________________
: ______________________________________________________
: ______________________________________________________
: ______________________________________________________
: ______________________________________________________
: ______________________________________________________
:______________________________________________________
: ______________________________________________________
: ______________________________________________________

APPLICANTS STATEMENT OF DECLARATION:

I, the undersigned, in the name of Allah Subhaanahu Wa Taaala, solemnly declare that all the above
information is true.
Applicants signature

: ______________________________________________________

Revision No
Revision Date
Reference No

Applicants name
Matric no.
Passport no.
Kulliyyah
Mahallah
Date

: 2
: 1 February 2010
: IIUM/ 215/12/ 10/1/ 7

: ______________________________________________________
: ______________________________________________________
: ______________________________________________________
: ______________________________________________________
: ______________________________________________________
: ______________________________________________________

Appendix B:
To: Officer In-charge of the International Students Division

DECLARATION AS THE TENANT OF THE HOUSE

Dear Sir,
I, (name) __________________________________________________, hereby declare as
the tenant of this house at (please write full address) _______________________________
_________________________________________________________________________
_________________________________________________________________________
I hereby attached the photocopy of the agreement between me, the house owner and the
agent (if applicable) for your reference.

TENANTS STATEMENT OF DECLARATION

I, the undersigned, in the name of Allah Subhaanallaahu Wa Taaala, solemnly declare
that all the above information is true.
Tenants signature
Tenants name
Matric no.
Passport no.
Kulliyyah
Mahallah
Date

: ______________________________________________
: _______________________________________________
: ________________________________________________
: ________________________________________________
:________________________________________________
: ________________________________________________
:________________________________________________

Revision No
Revision Date
Reference No

: 2
: 1 February 2010
: IIUM/ 215/12/ 10/1/ 7

Appendix C:
To: Officer In-charge of the International Students Division

ALLOWING IIUM INTERNATIONAL STUDENT TO STAY TOGETHER

Dear Sir,
I, (name) __________________________________________, as the tenant (i.e. parent/
guardian or housemate) of this house at (please write your full address)________________
_________________________________________________________________________
_________________________________________________________________________
____________agree to allow the following student to stay with me:
Students name
Passport no.
Matric no.
Kulliyyah
Mahallah

: ________________________________________________
: ________________________________________________
: ________________________________________________
: ________________________________________________
: ________________________________________________

TENANTS (i.e. Parent/Guardian or Housemate) STATEMENT OF DECLARATION:

I, the undersigned, in the name of Allah Subhaanallaahu Wa Taaala, solemnly declare

that all the above information is true.
Tenants signature
Tenants name
Passport/identity card no.
University/Institution
Faculty/Kulliyyah
Relationship with Applicant

: __________________________________________
: __________________________________________
: __________________________________________
: __________________________________________
: _______________________________
: __________________________________________

Revision No
Revision Date
Reference No

: 2
: 1 February 2010
: IIUM/ 215/12/ 10/1/ 7