Online Application Form

Programme of Choice

First Choice*

Second Choice*

Third Choice

Forth Choice

Country of Choice

First Choice*

Second Choice*

Third Choice

Forth Choice

Student Particulars

Full Name as per IC*

Identity Card / Passport Number*

Date of Birth*

Gender*

Male

Female

Mobile Number*

Home Landline Telephone Number

Postal Address*

Parents / Guardians Particulars

Parent/Guardian's Name*

Relationship*

Contact Number*

Email address*

Occupation*

Monthly Income (RM)*

Student's Qualifications

Academic Qualifications*

SPM

O Level

Others

Year*

School Name*

Mandatory Subjects

Bahasa Malaysia (For Malaysian Only)

English Language*

Mathematics*

Additional Mathematics

Chemistry

Physics

Biology

Other Subjects

Subject

Grade

Subject

Grade

Subject

Grade

Subject

Grade

Subject

Grade

Subject

Grade

Subject

Grade

Subject

Grade

Subject

Grade

Subject

Grade

Year

CGPA / Pointer / Aggregate / Percentage

School Name

Mandatory Subjects

Pengetahuan Am (For Malaysian only)

English Language

Mathematics

Physics

Chemistry

Biology

Other Subjects

Other Academic Qualification

University / College

Programme

Performance / Results

Duration of Study

Graduation Year

Hostel Accomodation

Do you need hostel accomodation?*

Yes

No

Declaration*

I declare the information provided in connection with this application is true and correct. I understand that Jay Excel Medic reserves the right to vary or reserves any decision regarding admission or enrolment made on the basis of incomplete information. I also agree to abide by all Jay Excel Medic rules and regulations.