SPACE UTM : Admission

Admission

UTM Summer Courses Online Application for Admission

Important : In order to be considered for admission you must complete this application form and submit the following items: official transcript(s), application fee if MYR60.00 (USD20.00) (non-refundable, check or credit card made payable to SPACE, Universiti Teknologi Malaysia)

Personal information

First Name:

Last Name:

Sosial Security/Passport #:

Date of Birth:

Student ID:

Citizenship:

Gender:

Address

Street:

City:

State:

Zip/Postal code:

Country:

Email:

Telephone (Home):

Cellphone:

Emergency Notification Information

First Name:

Last Name:

Street:

City:

State:

Zip/Postal Code:

Phone:

Email:

Academic Information

Current School:

Graduation Date:

Major:

Current Academic Standing:

Please indicate up to three programs in which you are most interested.

Program Choice 1

First Choice:

Session / Date:

Year:

Program Choice 2

Second Choice:

Session / Date:

Year:

Program Choice 3

Third Choice:

Session / Date:

Year:

If your first choice is full, would you like to :

be waitlisted for your first choice? OR

be assigned to your second or third choice?

Experience and Interests

Please list any additional experience, membership, research or field experience, extra curricular activities or off-campus study.

Health Insurance (Required for all students)

(Students who do not have health insurance coverage for international emergencies will be enrolled in the Summer Course plan and charged MYR60 (USD20) premium)

If you have any special medical, physical, religious, dietary or academic needs to be aware of in order to accommodate your participation, you should notify UTM. Without having the information at least 30 days prior to the commitment of a program, UTM cannot ensure appropriate support services for your needs

Payment

Please be sure to check the authorization box below:

I authorize UTM to charge my credit card.

(You will have the opportunity to discuss these options with your counselor)

Credit Card:

Cardholder's Name:

Amount:

Card Number:

Expiration Date:

Academic Reference

Last Name:

First Name:

Street:

City:

State:

Zip/Postal Code:

Phone:

Email:

Occupation:

School/Faculty: