Application Instruction: Please Print out the application form and complete each item where indicated.

Essays should be typed and appended to the application. Send completed application forms to Admissions office address below by regular post or you may transmit it by fax. Perdana University Graduate School of Medicine Admissions Office Suite 5.3 5th Floor Wisma Chase Perdana Off Jalan Semantan Damansara Heights 50490 Kuala Lumpur, Malaysia Phone Number: 6-03-2718-3721 Fax Number: 6-03-2718-3741 Email: admissions@perdanauniversity.edu.my Applicant Information 1. Name as on NRIC, or passport for international applicants:

2. Please list all other names that are used by you: (i.e., titles, nicknames, etc.)

3. Date of Birth: 4. Gender: 5. Ethnicity : Religion: Male

Female Chinese Buddhist

(dd-mm-yyyy) (check one)

Malay Muslim

Indian Hindu

Other: ______________
specify

(check one)

Other: _____________
specify

(check one)

6. Country of Citizenship: Malaysia Citizen NRIC number: -

International Students:

Passport No. Expiry Date (dd/mm/yyyy)

7. Legal Permanent Address Street Address: City: State or Province: Postal Code and Country: 8. Current Preferred Mailing Address: Street Address: City: State or Province: Postal Code and Country: Phone: E-Mail Address: 9. Name and Address of Parent, Guardian, or Nearest Relative: Name: Relationship to Applicant: Street Address: City: State or Province: Postal Code and Country: Phone: E-Mail Address: 10. Family Background Indicate positions held and include names of institutions where they are employed. (If applicable, please state if retired or deceased and include former occupation.) Name Father: Mother: Siblings: Colleges / Universities Attended Degree Occupation Mobile: Mobile: Dates Effective: (dd/mm/yyyy)

(Please notify the admissions office of any change and include dates of holidays and vacations)

Education History: 11. Please indicate the education institution you attended prior to University: Name of institution Date Certificate Conferred (dd-mm-yyyy)

Location (City and State or Province) 12. Check the type of pre-university program you completed: SPM O-Levels Matriculation STPM A-Levels
specify

International Baccalaureate

Other :_________________________

(A detailed official transcript is required for the programs) you completed)

13. Colleges and / or Universities Attended: College / University Name Major or Area of Concentration Dates Attended
(months and years)

Degree Type

Date Degree Conferred

(mm/yyyy)

(Note: A World Education Services Evaluation is required for each University attended outside of Malaysia, Canada and the United States. Please see instructions)

14. On a 4 point scale (A+/A=4, B=3, C=2, D=1, F=0) : Indicate your first degree Cumulative Undergraduate GPA 15. If you attended graduate school, indicate your Cumulative Graduate GPA, (4 point scale): 16. If you are currently attending university and/or do not have a final CGPA, please state your predicted results as verified by a university official: Standardized Tests: 17. If English is not the primary language at the University you attended, you must submit scores from one of the following tests: Test of English as a Foreign Language (TOEFL): Date Taken Listening Reading Writing Speaking

International English Language Test System (IELTS): Date Taken Listening Reading Writing Speaking

If you have not taken the TOEFL or IELTS, but plan to do so, please indicate which of the two exams you will take and the date scheduled: TOEFL or IELTS Date (dd-mm-yyyy)

18. The MCAT must be taken by all applicants. Please see the instructions for details 18a. If you sat for the MCAT, please indicate the date and your scores: Date Verbal Physical Science Biological Science Writing Sample (dd-mm-yyyy)

18b. if you plan to sit for the MCAT in the future, indicate the date: 19. Other Standardized Exams 19a. If you sat for the SAT exam, indicate your scores: Date Critical Reading Writing

Mathematics

19b. If you sat for the GRE exam, indicate your scores: Date 20. Academic Record 20a. Have you ever attended a medical or dental school? Yes No Verbal Quantitative Analytical Writing

20b. Have you ever discontinued attendance at or been dismissed from any college or university? Yes No

20c. Have you ever been subject to disciplinary action of any kind or placed on probation by a college or university? Yes No 21. Have you ever been convicted of a criminal offense, or are there criminal charges pending against you? Yes No If the answer to any part of item #20 or 21 is yes, give specific details below:

22. If you have already received your Bachelors degree, please describe what you have been doing since graduation, and your plans for the upcoming year.

23. If you interrupted your college education for a semester or longer, please describe what you did during that time.

24. List below any academic honors or awards you have received since entering university: Name of Award Reason for Award Date Received
(mm/yyyy)

25. List information about your paid employment since entering university Name of Employer Position Held Average Hours Worked per Week Dates of Employment
(mm/yyyy to mm/yyyy)

26. List below your major unpaid community service and volunteer activities Name of Organization Describe your degree of involvement and position held, if applicable: Average Hours Worked per Week Dates
(mm/yyyy to mm/yyyy)

27. List below your extracurricular activities, for example: clubs and hobbies, etc. organizations in which you were involved, participation in sports, interests you may have in art or music, hobbies, etc. Name of Activity Describe your degree of involvement and position held, if applicable: Average Hours Worked per Week Dates
(mm/yyyy to mm/yyyy)

28. Research. If applicable, describe any research you have conducted. Name of Institution Name of the person who supervised your work, and his or her email address Dates
(mm/yyyy to mm/yyyy)

Description of Research. If applicable, indicate Papers and/or Abstracts authored:

Name of Institution

Name of the person who supervised your work, and his or her email address

Dates
(mm/yyyy to mm/yyyy)

Description of Research. If applicable, indicate Papers and/or Abstracts authored:

Personal Statement Essay: 29. Personal Statement Please append your typed essay to this application.The maximum length is 5,000 characters. The essay should be saved with your name as header of document and noted as Appendix 1. Theme Essays (Items 30, 31 and 32) Please append your typed themed essay to this application.The maximum length is 1,500 characters. 30. Briefly describe your most rewarding experience or some achievement of which you are particularly proud. The essay should be saved with your name as header of document and noted as Appendix 2. 31. Why do you want to attend medical school in Malaysia and how will this influence your plans for a career in medicine? The essay should be saved with your name as header of document and noted as Appendix 3. 32. Explain why you believe you are prepared to study the Genes to Society curriculum taught at Perdana University Graduate School of Medicine. The essay should be saved with your name as header of document and noted as Appendix 4. 33. Letters of Evaluation: 33a. Undergraduate Advisor or Tutor: Name: Institution: Position: 33b. Two (2) additional letters from faculty members in science departments who taught you: Name: Institution: Position: Name: Institution: Position:

33c. Optional: other letters from employers or non science faculty. If you have a graduate degree, significant research experience or full time work employment of a year or more, it is advisable to send letters from persons who have supervised your work. Name: Institution: Position: Name: Institution: Position:

34. I understand that the Admissions Committee will not consider this application until all supporting documents have been received, and that it is to my interest to see that these items are sent to the Perdana University Graduate School of Medicine without delay. I understand that the Admissions Committee reserves the right to request additional information from applicants, if needed, to assess their candidacy for admission. Furthermore, I am aware that all credentials received by the Admissions Committee in support of my application, including transcripts and letters of recommendation, are considered confidential and I will not be permitted to have access to these items. I have read and understand the Technical Standards Policy of Perdana University Graduate School of Medicine. My signature to this application certifies that all of the information contained in my application is factually correct, honestly presented, and contains no significant omissions. If at a later date it becomes clear that this is not so, I agree that Perdana University Graduate School of Medicine may revoke any offer of admission it makes to me or dismiss me from the University. If I am admitted to study at Perdana University Graduate School of Medicine, I agree that I will honor the University s academic and ethical standards and that I will abide by all requirements established by the University concerning academic progress, health, and conduct. I agree that the University may dismiss any student whose academic standing is unacceptable or whose general conduct jeopardizes the community or is otherwise unacceptable.

Signature : ___________________________________ Date:___________________

When you have completed the application form, please make a copy for your records.