REGISTRATION

DOCUMENT
October 2014 Intake

Appendix A(3) Students Biodata Form

Appendix B(1) Medical Certification Form
Appendix B(2) Financial Guarantee Form
Appendix B(3) Students Declaration Form
Appendix B(4) Finances Declaration Form
Appendix C Students Pledge

Kindly complete and submit this

document on the scheduled
orientation day.

REGISTRAR OFFICE (Admission Unit)

APPENDIX A (3)

STUDENTS BIODATA FORM

PERSONAL PARTICULARS (CAPITAL LETTERS)

Please affix
a copy of your
passport sized photo
here.

STUDENT ID NO. : ________________________________

Full Name
Date of Birth

IC No.

Marital Status

Gender

Race

Religion

Contact Number
Permanent Address

Correspondence Address

Parents / next of kin who can be contacted in case of emergency

Name
Address

Contact No.
IC No.
1

FAMILY BACKGROUND :
PARTICULARS
Name

Father / Guardian

Mother / Guardian

IC. No
Age
Race
Religion
Permanent Address

Correspondence Address

Occupation
Employer
Address of Employer

Monthly Salary
Telephone
(House)
(Office)

:
:

NAME OF SIBLINGS IN THE FAMILY :

Name

Age

Marital Status

No.

Occupation

Contact No.

EDUCATIONAL BACKGROUND :

No.

School / Institution

Duration of
Study

Highest
Qualification

Year
Obtained

Field of Study

MUET / TOEFL / IELTS

Score : ___________________________

WORKING EXPERIENCE (if applicable) :

No.

Name of Employer

Address

Designation

Duration

DECLARATION OF STUDENT

I hereby declare that all information given is complete and correct. I understand that if there is any omission
or negligent misstatement, the university shall have the right to reject my admission.

______________________

_____________________

Students Signature

Date

APPENDIX B (1)

MEDICAL CERTIFICATION FORM

HEALTH EXAMINATION GUIDELINES
FOR ENTRY INTO
MULTIMEDIA UNIVERSITY

1. Please read the instructions carefully before filling in the form.

2. This form has 4 sections:
a. Section 1 (Part A and B) to be filled by the candidate; and
b. Section 2, 3 and 4 to be filled by the examining doctor.
3. Please complete all the tests required in this form.
4. The university only accepts medical examination done within 60 days before registration or within
30 days after registration.
5. Chest X-ray done within 6 months prior to registration can be accepted.
6. Please keep the chest x-ray film for future verification, if required.
7. The university reserves the right to request full medical check-up or any specific laboratory tests
should there be any doubt in the medical report submitted. All costs involved shall be borne by the
candidate.
8. The university reserves the right to REJECT any application:
a. Based on the results of the Health Examination; or
b. Should there be any evidence that the applicant has given false information in the Health
Examination report or any supporting documents.
9. Before submission please make a photocopy of this Health Examination Report and all documents
pertaining to this Health Examination for your own reference.

SECTION 1 (To be completed by candidate)

Candidate must complete this form and hand it to the Medical Officer at the time of examination together
with the offer letter.
(PART A)
Student ID No.

IC No

Name
Programme
Date of Birth

Gender

Marital Status

Contact No

(PART B) Please tick () in the relevant box

Declaration of self and family illness. Explain in full if you or your family has any of the following illness.
* Immedidate family refers to father, mother, brothers and sisters; if married refers to spouse and
children.
SELF
MEDICAL PROBLEMS
YES

NO

IMMEDIATE
FAMILY
YES
NO

If Yes please state

1. Congenital or inherited disorder

2. Allergy
3. Mental illness
4. Fits, stroke, other neurological disease
5. Diabetes Mellitus
6. Hypertension
7. Heart or vascular disease
8. Asthma
9. Thyroid disease
10. Kidney disease
11. Cancer
12. Tuberculosis
13. Drug addiction
14. AIDS, HIV
15. History of surgery
16. Other illness

Current medication (Long term) (if applicable)

............................................................................................................................................................
...........................................................................................................................................................

I hereby declare that the information given above is true. I understand that my application will be rejected if
there is any false information given.

Students Signature : ____________________________

5

Date : _______________

SECTION 2 - PHYSICAL EXAMINATION

(To be filled by examining doctor)
1. BASIC MEASUREMENT
HEIGHT :

BLOOD PRESSURE :

mmHg

WEIGHT :

kg

PULSE RATE

/ min

VISION TEST :

COLOR VISION TEST

(including color blindness):
NORMAL / ABNORMAL*
*Additional comment (if any):

Unaided: (R) _______ (L) _______

Aided

: (R) _______ (L) _______

2. GENERAL EXAMINATION
ITEM
a. DEFORMITIES

YES

NO

COMMENT

b. PALLOR
c. CYANOSIS
d. JAUNDICE
e. OEDEMA
f. SKIN DISEASES

3. SYSTEMIC EXAMINATION
ITEM
a. EYES (including funduscopy)

NORMAL

b. EARS
c. NOSE
d. ORAL CAVITY / THROAT
e. NECK
f. HEART
g. LUNGS
h. ABDOMEN / HERNIA ORIFICES
i. NERVOUS SYSTEM
j. MENTAL CONDITION
k. MUSCULOSKELETAL SYSTEM
6

ABNORMAL

COMMENT

SECTION 3 - INVESTIGATIONS (To be filled by examining doctor)

URINE TEST
ITEM

DATE TAKEN

a. ALBUMIN
b. SUGAR
c. MICROSCOPIC
d. MORPHINE

CHEST X-RAY INFORMATION

DATE TAKEN
PLACE TAKEN
REPORT

RESULT

SECTION 4 - CERTIFICATION BY THE EXAMINING DOCTOR

Please tick () in the relevant box

I certify that I have on this date _________________________________ examined Mr / Ms

___________________________________________________ IC No. ____________________________
and found him / her:IN GOOD HEALTH AND IS FIT FOR ADMISSION INTO MULTIMEDIA UNIVERSITY

HAVING THE FOLLOWING MEDICAL COMPLICATION(S) (Please specify) :

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

UNDERGOING TREATMENT FOR (Please specify) :

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Date:

Signature of Doctor
Name of Doctor
Qualification
Hospital/Clinic :

Official Stamp :

:
:
:

APPENDIX B (2)

FINANCIAL GUARANTEE FORM

STUDENT ID NO. : .. PROGRAMME : ...

GUARANTOR
1.

I hereby agree to be the Guarantor of the student named : .. I.C No.

............. (Student) during the period of the Course (Name of Course)
...... at Multimedia University, Jalan Ayer
Keroh Lama, 75450 Melaka / Multimedia University, Jalan Multimedia, 63100 Cyberjaya, Selangor.
As the Guarantor, I hereby guarantee that I shall settle all outstanding debts incurred by Student and
owing to Multimedia University (University) within the time specified. I also give my guarantee that
Student, shall: (i) complete his/her course of study within the time specified by University and (ii)
abide to the Constitution of University and its rules and regulations. If Student is found to have
breached any rules or regulations, I agree to pay damages and/or compensation as demanded by
University or further legal action can be taken against me.

2.

My personal particulars are as follows :i.

Name

.....

ii.

I.C No./Passport No.

iii.

Occupation/Post

.....

iv.

Office

Employers Address

.
.............................................

v.

Office Telephone No.

vi.

Home Address

..............
................

vii.

House Telephone No.

viii.
ix.

Monthly salary
Total monthly income
with allowances

(basic)

x.

xi.

Net Income after

statutory and legal
deductions

Properties
a. Land (size & value) :
b. House (s) (Values by licensed Valuer) :
c. Other properties such as shop etc. :
9

Dependant :
Name of Dependant

Age

School

Monthly
Expenditure

1.
2.
3.
4.
5.
6.
I swear that all information given above is correct and true. If at any stage, any of the above information is
found to be incorrect, the University authorities reserve the right to take any action against me.

Yours faithfully

Postal Address

..
Guarantors Signature

.
.
.
Permanent Address

Date : ..

Note :
1.
2.

Those qualified to become Guarantor :Family members/Individual whose job is permanent and has a nett income of not less than RM1000.00 a
month.
Financial Institution such as banks, and other government organizations.

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APPENDIX B (3)

STUDENTS DECLARATION FORM

(Note: Please read the contents carefully and make sure you understand what each paragraph means
before signing it. This Declaration Form is a very important legal document and you should not sign it
unless you agree with all the terms contained herein).
1.

I understand and acknowledge that Multimedia University is the first private university where the
search of knowledge is for the pursuit of excellence and where the development of personality as
well as leadership character is of paramount importance.

2.

I solemnly promise to:

a)
Uphold the ideals, philosophy and objectives of Multimedia University and lead a life of total
commitment to the values of humanity, tolerance, honesty, hard work and good relationship
with my fellows, colleagues, lecturers and University staff. I shall also co-operate in the
promotion of an atmosphere of peace and orderly behaviour in and outside the University.
b)

Abide by the Constitution, Statutes, Rules and Regulations including the Discipline of Students
Rules and other documents framed by the University Authorities from time to time.

c)

Maintain good behavior in my relationship with other people in the University and not to indulge
in the abuse of drugs, free immoral mixing of the sexes or any form of entertainment prejudicial
to the good name of Multimedia University.

d)

e)

Respect the identity and way of life of the Muslims as well as the way of life of non-Muslim and
believers of other faiths both in and outside the campus, and not to do anything that would
tarnish the good name of Multimedia University.
Observe decency and modesty in behavior without imitating, introducing any undesirable and
immoral trend or fashion.

3.

I hereby declare that I accept as binding on me, as long as I am a student, all rules and regulations in
force at the time of joining and which might be framed subsequently. I shall submit to the discipline of
the University as exercised through its lecturers and administrative officers.

4.

I accept that the University shall have the right to reject my application without assigning any reason
whatsoever, if in the opinion of the appropriate authorities that my stay in the university is not
conducive to my colleagues or welfare of others in Multimedia University.

5.

The confirmation given in this Declaration Form is correct to the best of my knowledge and belief,
and in case of any misstatement or concealment of facts, the University shall have the right to refuse
my admission or expel me from the University.

Students Signature : ID No. ..

Students Name
IC. No.

: ...

: ...

Date : ...

Note: Any negligent miss-statement shall result in the automatic cancellation of all concessions.
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APPENDIX B (4)

FINANCES DECLARATION FORM

(1) I agree and promise herewith to pay all fees owing to the University within the due date imposed,
should my sponsor fails to settle them. I also agree to pay any late payment penalty or any other
payment(s) related to the late payment as imposed by the University.
(2) I agree that the University shall have the right to deduct from any scholarship/financial aid(s) given
to me in order to settle in part or all of any outstanding payments stated in (1) above.
(3) I agree that the University shall have the right to demand any outstanding payments stated above
from my Guarantors in the event that I leave the University before the completion of my course of
study.
(4) I also understand and agree that notwithstanding the completion or non-completion of my course of
study, the University can and will pursue/demand any outstanding payments owing to the University
after I have left the University. I agree that the University may engage any third party to collect on
its behalf, any outstanding payments from me and thus I give my consent herewith for my relevant
information to be disclosed to the said third party(s) by the University.
(5) I acknowledge and agree that the University has the right to revise its internal regulations including
its fees structures, whenever deemed necessary, without any prior notification to be given. I agree
to follow the revised/new regulations and fees accordingly.
(6)

i) I acknowledge and agree that I am providing valid contact information to facilitate any
transactions during and after the completion of my study and I will update the University should
there be any changes.
ii) If I do not claim for the refund of my deposit and any excess payment within one year from my
completion date and upon notification by MMU to my updated address, I hereby consent to the
said money to be given as (please tick the relevant box below) otherwise I agree that
the unclaimed deposit will be donated to the University.

Donation to the University,

Alumni,
Zakat,
Others, Please specify ____________________________________________

.
Signature of student

Name

: .

IC No.

: .

Date

: ....
12

APPENDIX C

STUDENTS PLEDGE

STUDENT ID NO

: ............................................

PROGRAMME

: ......

I solemnly declare that during the period of my study at this university,

a.

I shall abide by the Law of the country;

b.

I shall abide by the rules and regulations of Multimedia University (Student discipline) and any other
rules and regulations amended and created;

c.

I shall protect the good name of the university at all time and look after the property and facilities from
being destroyed by me or anyone else;

d.

I shall not be involved in any undesirable activity that will interfere with the administration and/or
academic function of the University; and

e.

I shall devote to my studies and shall fulfill all educational conditions required.

Students Signature

: ....

Name

: ..

IC No.

: ...

Date

: ..

13