APPLICATION FOR ADMISSION

PERSONAL DETAILS
APPLICANT'S NAME (according to IC/Passport):BINTANG ANANDA SAPUTRA

NATIONALITY:INDONESIA DATE OF BIRTH:16 APRIL AGE SEX (M/F) RELIGION ISLAM

2003 19 M
PASSPORT NO:E1357755 PLACE OF ISSUANCE: PALEMBANG VALID UNTIL: 17
NOVEMBER 2023 Please affix a passport-sized
MAILING ADDRESS: HOME/PERMANENT ADDRESS: photo here
KOMP.PATRA ABADI JL.ROSELLA BLOK A NO 10 KOMP.PATRA ABADI JL.ROSELLA BLOK A NO 10

POSTCODE: 30267 STATE: INDONESIA POSTCODE:30267 STATE:INDONESIA

HOUSE TEL NO.: NON H/P NO.: 082275839138 E-MAIL ADDRESS: [email protected]

QUALIFICATION DETAILS
GRADE / CGPA
LEVEL NAME OF SCHOOL / INSTITUTION YEAR OF PASSING
OBTAINED

O' Level (or equivalent)

SMA NEGERI UNGGUL 4 PALEMBANG 2021

A' level (or equivalent):

DIPLOMA (or equivalent):

Others (or equivalent):

PROGRAM OF CHOICE

1st CHOICE:POLITEKNIK NEGERI INTAKE: Mar May Nov Year: 2021

SRIWIJAYA
2nd CHOICE: INTAKE: Mar May Nov Year:

3rd CHOICE: INTAKE: Mar May Nov Year:

WORKING EXPERIENCE
EMPLOYER'S NAME & ADDRESS POSITION YEAR IN SERVICE

DO YOU NEED ACCOMMODATION ON CAMPUS? Yes No

PLEASE INDICATE (TICK) ACCORDINGLY:

I shall be privately sponsored by : parents guardians (Name: Tel No.: )

)

MEDICAL RECORD
PLEASE INDICATE IF YOU ARE CURRENTLY RECEIVING ANY MEDICAL TREATMENT FOR ANY HEALTH RELATED CONDITION:
FAMILY BACKGROUND
DETAILS FATHER MOTHER

FULL NAME
HERU SUPRIANTO LIES MARDIAH NINGSIH

PASSPORT NO

KOMP.PATRA ABADI JL.ROSELLA BLOK A NO 10 KOMP.PATRA ABADI JL.ROSELLA BLOK A NO 10

MAILING ADDRESS

HOME TEL NO.

NON NON

H/PHONE NO.
082177614894 082177614894

AGE (yrs)
49 51

NATIONALITY
INDONESIA INDOENESIA

RACE
NON NON

RELIGION
ISLAM ISLAM

OCCUPATION
WIRASWASTA WIRASWASTA

POST / POSITION

PALEMBANG PALEMBANG
NAME / ADDRESS
OF EMPLOYER

800 800
MONTHLY INCOME (RM)

DATE RETIRED NON NON

(if applicable)

NAME OF SIBLINGS SEX AGE

CURRENT SCHOOL / INSTITUTION LEVEL SPONSORSHIP
(and others supported by parents) (M/F) (yrs)
GILANG RISKY HERMAWAN M 23

CONTACT PERSON DURING EMERGENCY SITUATION

NAME: RELATIONSHIP WITH APPLICANT

ADDRESS (in Malaysia): HOUSE TEL NO.:

HANDPHONE NO
 DECLARATION BY STUDENTS:

I hereby declare that all the information given in connection with this application is true and correct. I understand that MSU
reserves the right to change or reverse any decision made regarding admission or enrollment which has been made based on
false or incomplete information. I also agree to to adhere to all MSU rules and regulations.

APPLICANT'S SIGNATURE DATE

THE FOLLOWING DOCUMENTS MUST BE ATTACHED WITH THE APPLICATION FORM. INCOMPLETE DOCUMENTS MAY CAUSE THE APPLICATION TO BE
REJECTED.

FOR OFFICE USE ONLY

This application is : The applicant is eligible for :

successful entry into Year 1

conditionally accepted* entry into Year 2 (Advanced Standing)

unsuccessful subject(s) exemption

Checked by: Endorsed by:

Date: Date:

Remarks*:
 GUIDELINES

This application must be fully completed in BLACK or BLUE pen/ball-point pen using BLOCK LETTERS

1 Students' full name as printed in passport

2 All personal data indicated in this form complies with the ACT of 555: Private Higher Educational Institutional Act 1996;
to ensure students'compliance with the Malaysian Immigration requirement.

3 Defaced by erasures or any kind of correcting fluids may results in the application not being accepted at the discretion
of MSU. Every amendment made must be clear and legible and should be countersigned in full by applicant.

4 Each completed application form must be accompanied by certified and clear copies of relevant documents (eg)
certified transcripts.

5 MSU reserves the right to require any applicant to appear in person before MSU management to ascertain the genuinity
of the information provided in the application form.

6 MSU shall not be liable to return the submitted application form or any documents(s) and/or transcripts attached.
Applicant should not sent original copies of the documents.

7 Each completed application form must be accompanied by a remittance of RM500.00. Application Fee (NON
REFUNDABLE) either by Money Order or Postal Order or Banker's Draft or Cashier's Order or Personal Cheque or
major Credit Cards must be made payable to MSU Holdings Sdn Bhd and 'A/C Payee Only'.
8 All applications for subject(s) exemptions must be attached with certified copies of syllabus from previous semester
course.

9 MSU reserves the right to reject/withdraw any application which does not adhere to the above instructions or which are
illegible or which are accompanied by remittance(s) improperly drawn.

10 MSU shall not be responsible for any loss or non receipt of the said payment nor shall MSU be accountable for any
expenses incurred.

11 MSU reserves the right to reject/withdraw any offer made or vary/cancel any of the course should the circumstances so
required.

Please direct all enquiries in respect to the Application Form to the Admission & Record Department, Registrar Office.

Completed form must be returned to:

The Registrar,
Management and Science University (MSU),
University Drive
Off Persiaran Olahraga, Seksyen 13
40100 Shah Alam,
Selangor Darul Ehsan.
Tel: 03 55216868 Fax: 03 5511 2848
www.msu.edu.my