INTERNATIONAL APPLICATION FORM

Menara City U, No. 8, Jalan 51A/223, 46100 Petaling Jaya, Selangor.

Tel: +603-7949 1600 | Fax: +603-7957 7721 | E-mail: imo@city.edu.my
www.city.edu.my |

FOR OFFICE USE ONLY

Student ID No.:

Intake JAN MAY SEP

COURSE APPLIED

FOUNDATION
Foundation in Arts (Graphic Design & Multimedia) Foundation in Arts (Communication) Foundation in Arts (English)
Foundation in Arts (Built Environment) Foundation in Arts (Fashion Design) Foundation Studies in Science
Foundation in Business Foundation in Information Technology

DIPLOMA
Diploma in Accountancy Diploma in Islamic Banking Diploma in Human Resource Management
Diploma in Management Diploma in Office Management Diploma in Business Management
Diploma in Medical Laboratory Technology Diploma in Environmental Health Diploma in Nursing
Diploma in Occupational Safety & Health Diploma in Early Childhood Education Diploma in Corporate Communication
Diploma in Mass Communication Diploma in Information Technology Diploma in Culinary Arts
Diploma in Hotel Management Diploma in Interior Design Diploma in Architectural Technology
Diploma in Civil Engineering Diploma in Mechanical Engineering Diploma in Fashion Design
Diploma in Graphic Design

BACHELOR
Bachelor of Accounting (Hons) Bachelor of Business Administration (Hons) Bachelor of Engineering Management (Hons)
Bachelor of Science (Accounting & Finance) (Hons) Bachelor of Graphic Design (Hons) Bachelor of Multimedia (Hons)
Bachelor of Science (Hons) (Architectural Design) Bachelor of Interior Design (Hons) Bachelor of Civil Engineering With Honours
Bachelor of Mechanical Engineering With Honours Bachelor of Biomedical Sciences (Hons) Bachelor of Environmental Health (Hons)
Bachelor of Occupational Safety & Health (Hons) Bachelor of Hospitality Management (Hons) Bachelor of Fashion Design (Hons)
Bachelor of Computer Science (Hons) (Software Engineering) Bachelor of Information Technology (Hons) Bachelor of Communication (Hons) (Journalism)
Bachelor in Nursing (Hons) Bachelor of Mass Communication (Hons) Bachelor of Applied Psychology (Hons)
Bachelor of Communication (Hons) in Corporate Bachelor of Education (Early Childhood Bachelor of Education in Teaching of English
Communication Education) Honours As A Second Language (Honours)
SECTION A: PERSONAL PARTICULAR
Full Name (as per IC/Passport) :
Passport Number : Religion :
Gender : Male Female Race :
Date of Birth : _ _ Age : Year
Email : Nationality :
Home Telephone No. : Mobile No. :
Permanent Address :
(Home Country)

Town : Postcode :
Parent/ Guardian Name :
Relationship : Parents Brother/ Sister Others :
Occupation :
Home Telephone No. : Mobile No. :
Correspondance Address :

SECTION B: EMERGENCY CONTACT

Name :
Contact Number : Mobile :
Relationship : Parents Brother/Sister Cousin Others :

SECTION C: ACADEMIC/PROFESSIONAL QUALIFICATIONS

Highest Examination Passed
‘O’Level ‘A’ Level Diploma Bachelor Others :

Exam Year Name Of Examination School/Institution Result

English Language Achievement

TOEFL IELTS MUET Others (Specify) :

SECTION D: WORKING EXPERIENCE (IF ANY)

Company Position From (Year) To (Year)

SECTION E: SUPPORTING DOCUMENT (INTERNATIONAL STUDENTS) Please attach the following when you submit your application

Payment for Visa (EMGS) & Application Fee

Health Examination
Swift Code:
Complete Application Form MBBEMYKL
Photographs (passport-sized, white background)
Scan Copy of Passport - photocopy (cover to cover)
High School / Diploma / Degree / Master certificates & transcripts or result in English Language with certified true copy
Resend Resume/ CV (if applicable)
Payment can be done via Cash, Credit Card, Bank-In or Bank-Draft to be made payable to U.C.I Education Sdn. Bhd.

Payment Option 1: Flywire payment http://city-edu-new.flywire.com/ Account Name : U.C.I. EDUCATION SDN BHD
Name of Bank : Malayan Banking Berhad
Account Number : 5123 3433 4755
Payment Option 2: Maybank transfer Bank Address : 18A, Jalan 14/14, 46100 Petaling Jaya, Selangor
SECTION F: OTHER INFORMATION
Where did you hear about us?

Facebook Twitter Friends Agent

Instagram Website Exhibition Others :

SECTION G: TERMS AND CONDITIONS FOR ADMISSION

Important
Students are advised to read carefully and understand fully the terms and conditions set out in Section I before proceeding to
the next section of this application form.

1. A student is considered fully enrolled upon subject enrolment 8. A transfer fee of minimum RM300 is charged for every inter-
and payment of fees due in the semester (including deposits). programme transfer.
2. Fees payable are shown in the programme fee structure. 9. Fees paid are not transferable except under the
Please note that City University reserves the right to review and circumstances stated below and provided with a written
revise fees annually. The fees indicated in the programme fee request (accompanied by official supporting documents)
structure may not be applicable in the subsequent semesters that has been submitted to the Head of School or Director
(except the total tuition fee payable). of Programme.
3. Fees due in the semester must be paid in advance in the first • Transfer due to call for National Service.
semester and before the first day of class in the subsequent • Transfer due to medical reasons.
semesters. Failure to pay fees on time may result in the student 10.The refundable/ transferable amount of fees or deposits
being barred from attending classes, examinations and is determined by clauses 5 and 8, and after the deductions
access to campus facilities. made against any fees or payments due owing to City
4. No fees should be paid to anyone except to City University. University.
No agent has been authorised to collect the fees on behalf of 11.City University reserves the right to forfeit any payment
City University and City University will not be responsible made by the student or Sponsor, into event that;
for any funds that transferred to any other party other than a. A student remains inactive for 6 months without
City University. notifying the Registrar in writing.
5. Enrolment and general fees are NOT refundable and NOT b. A student is expelled/ suspended or discontinues the
transferable (this includes approved and rejected applications). programme due to misconduct.
In addition: c. A student drop all the subjects before the ADD/DROP
a. The registration fee, application fee, student annual fee and deadline and subsequently follow up with
Education Malaysia Global Services (EMGS) application fee a withdrawal from City University, the University will
are not refundable nor transferable under any circumstances. charge back the full fees based on the initial approved
b. All initial fees paid as stipulated in the Letter of Acceptance / course selection.
Conditional Letter of Offer / Conditional Letter of Acceptance 12.In the event of non-payment or late payment of any fees or
are not refundable. any part thereof without prior written approval from the
6. Notice of withdrawal from the programme / deferment must Registry, City University reserves the right without further
be given at least 60 days prior to the commencement of the notice to;
semester. a. Charge administrative charges on each month of
- For international students, no fees are refundable if the default from the date of payment due until the date of
student provides notices within 60 days before the settlement of the fees and / or charge a reactivation fees;
commencement of the semester. b. Bar the student from attending classes, examinations and
- The commencement of the semester is based on the date access to campus facilities and / or withholding
stated in the Visa. The administrative charge is applied. submission of answer scripts / assignment for making or
- In the event that a student withdraws from the programme withholding examination results, transcripts or certificates
to join another educational institution after obtaining visa and / or suspend provision of any services and / or take
under City University, an administrative fee of RM1,500 will such action where it deems appropriate;
be charged for issuing of a release letter. c. Suspend or terminate the student from the programme
- In the event that a student fails to complete a course of and subsequently proceed to cancel the student visa
study, City University is not obliged to return any part of the upon notifying the relevant authorities, i.e. police and
fees paid by or on behalf of the student. immigration department and the respective embassy;
7. The tuition fee world be refunded (if any) to the student d. Take such other recovery measures including
without any interest charged by the University, after deduction commencing legal proceedings or referring to external
of all damages, losses suffered by City University due to a fault debt collectors.
or negligence of the student. In order to claim the refund; 13.A student on conditional offer whose actual results do not
a. The student is required to submit the relevant forms for meet the entry requirements of the programme is eligible
approval by City University within 15 days of completion or for a prorated refund of the tuition fees paid.
termination from the program or approval to withdraw from 14.A copy of the City University Student Handbook has been
the Programme. Failure to do so will result in the advance posted on the portal. Students are expected to read and
deposits being forfeited. abide by all rules and regulations of City University including
b. For graduated students, the relevant forms must be policies on the use of campus facilities.
submitted within 2 months from the convocation date. 15.City University reserves the right to review and amend the
c. All applications should ONLY be duly submitted in the rules and regulations (including policies) at anytime.
manually form and not in any other manner whatsover.
SECTION H: ACKNOWLEDGEMENT, AGREEMENT AND CONSENT
Applicant
1. I have read and fully understand all the terms and conditions governing 11. If tuition fees are paid by an organisation (“Sponsor”), authorise City Universi-
admission before submitting this application. ty to release fee and academic progress information to my Sponsor. I also
2. I hereby declare that all information provided by me in this form, including consent to City University releasing fee and academic progress information to
those information given in all other documents submitted with this form, is my parent or guardian.
complete, true and accurate. I also acknowledge that City University 12. I authorise and grant City University the right to use my personal
reserves the right to vary, amend or reverse any decision regarding information such as name, credentials, academic record, image and spoken
admission and enrolment made on the basis of non-attainment of and written records of my activities at City University, in posters, leaflets,
minimum entry requirements, incomplete or inaccurate information, brochures, advertisements, websites, films, electronic recordings and
including pre-requisite results to enrol into a programme. the like for marketing and promotion of City University’s corporate image and
3. I understand that the Offer Letter issued to me will become void if I fail to programs of study, and / or any purposes incidental to it.
submit all the relevant documents and pay the required course fees by the due I understand and agree that City University and its authorised
date. I agree to inform the Registrar in writing of any change in the 13. representatives shall unlimited use of, and exclusive rights, titles and interests
information given herein, and I understand that City University will not be including copyrights over the materials mentioned in this Section, during
liable as a result of my failure to do so. and after my graduation from City University.
4. I understand and agree that City University shall forfeit all payment paid by me I understand and agree that if I revoke my consent to any of the items specified
or Sponsor if I remain inactive for 6 months without notifying the Registrar 14. in clauses 12 and 13 herein, I must do so in writing forms to the Registrar and
in writing. I understand and agree that City University shall cancel my student that all actions taken by City University prior to the revocation in exercise of
Visa and notify the relevant government agencies / embassy / bodies if I their rights in respect of me will not be affected.
remain inactive for 6 months without notifying the Registrar in writing (This is I understand and agree that City University shall release my
applicable to foreign students only). examination results and my academic record to my parents as and
5. I understand and agree that any fees, deposits and / or monies due to me that 15. [ ] (please tick to indicate consent) I would like to receive marketing
remain unclaimed for a period of one year or more from the date of my materials from City Education Group including future events,
becoming inactive in my program of study, will be transferred to any 16.a promotions, updates and any other marketing activities.
nominated education or charitable fund without further reference to me. [ ] (please tick to indicate consent) I would like to receive marketing
6. I understand and agree to use the technology resources and facilities at City materials from City Education Group’s affiliates and its selected business
University for educational, academic, research and study purposes only and City 16.b partners including future events, promotions, updates and any other
University shall not be held liable for any violation of rules and regulations marketing activities.
relating to those resources perpetuated by me.
7. I have read the Personal Data Protection Notice.
8. I consent to City University processing my personal data (including sensitive
personal data as defined in the Personal Data Protection Act 2010) to
assess my application, create an enrolment record on the student
database, undertake statistical analysis and meet statutory reporting
requirements. It will be accessed strictly for these purposes only and
Signature of Student
disclosed to the government agencies when required.
9. I also hereby warrant that I have obtained all necessary consent from the third Name :
parties where I have provided their personal data as part of my
application (such as information relating to my parents) and I have
extended a copy of the Notice to the third parties.
10. I consent to educational institution at which I have previously been a Passport No. :
student and/or my current or any past employer, providing City University with
information, which they hold about me for the purpose of City University verifying Date :
my grades and/or qualifications and/or experience.

Parent / Guardian (if Applicant is below 21 years old)

1. I hereby apply for his/her place of study at City University and undertake to pay the 9.a. [ ] (please tick to indicate consent) I would like to receive marketing materials
full fees for this programme until complete. from City Education Group including future events, promotions, updates and any
2. I hereby agree to pay all fees due on the dates stipulated by City University. other marketing activities.
3. I understand and agree that City University has the right to bar my child/ward, 9.b. [ ] (please tick to indicate consent) I would like to receive marketing materials
including termination of enrolment, due to default in payment of fees. from City Education Group’s affiliates and its selected business partners including
4. I have also read and fully understand all the terms and conditions governing future events, promotions, updates and any other marketing activities.
admission for this application.
5. I have read the Personal Data Protection Notice and consent to City University
processing my personal data and the Applicant’s personal data in accordance to the
Personal Data Protection Act 2010.
6. I also hereby warrant that I have obtained all necessary consent from the third parties Signature of Parent or Guardian
where I have provided their personal data as part of this application (such as
information relating to emergency contacts) and I have extended a copy of the Name :
Notice to the third parties.
7. I consent to any educational institution at which the Applicant has previously been a
student and/or the Applicant’s current or any past employer, providing City University
with information, which they hold about the Applicant for the purpose of City Passport No. :
University verifying the Applicant’s grades and/or qualifications and/or experience.
8. If tuition fees are paid by an organisation (“Sponsor”), I authorise City University to Date :
release the Applicant’s fee and academic progress information to the Sponsor.

SECTION I: BANK ACCOUNT OPENING

Students enrolled with the University are encouraged to open a personal saving account for education purposes with Affin Bank/Affin Islamic Bank. We are committed to
protect your privacy in accordance with the Personal Data Act 2010 of Malaysia (PDPA).
By signing, I am declaring that I expressly agree to disclosure my personal data for account opening purposes.

Name :

Passport No. :
Signature of Student Date :

SECTION J: FOR OFFICE USE

MARKETING ADMISSION
Introducer Information Application Status
Name of Introducer : Date : Full Offer Conditional Offer Rejected
Verified by : Date :
Approved by HOD :

Remarks :