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Nationality
Established by: MANIPAL EDUCATION MALAYSIA SDN. BHD. (912256-H)
Malaysian  International 
APPLICATION FOR ADMISSION
SECTION A PROGRAMME PREFERENCE
Please indicate your choice of programme by marking it in the box. 1 – Most Preferred and 5 – Least Preferred. You are allowed to make up to 5 choices.
CENTRE FOR FOUNDATION STUDIES □ Diploma in Civil Engineering
□ Foundation in Business Studies □ Diploma in Mechanical Engineering
□ Foundation in Engineering □ Diploma in Electronics Engineering (Computer)
□ Foundation in Science

SCHOOL OF SCIENCE AND ENGINEERING SCHOOL OF MANAGEMENT & BUSINESS

□ Bachelor of Chemical Engineering (Hons) □ Diploma in Business Administration

□ Bachelor of Civil Engineering (Hons) □ Diploma in Mass Communication
□ Bachelor of Computer Engineering (Hons) □ Bachelor of Business Administration (Hons)
□ Bachelor of Electrical and Electronics Engineering (Hons) □ Bachelor of Business Administration (Hons) (International Business)
□ Bachelor of Mechanical Engineering (Hons) □ Bachelor of Accounting (Hons)

□ Bachelor of Science (Biotechnology)(Hons) □ Bachelor of Mass Communication (Hons)

□ Bachelor of Computer Science (Hons) □ Master in Business Administration (MBA)

□ Master in Biotechnology by Research  Bachelor of Business Administration (Hons)- ODL

□ PhD. in Biotechnology by Research □ English Enhancement Programme (E E P)

SECTION B PERSONAL DETAILS

Applicant’s Particulars
Complete ALL information in ALL sections with BLOCK LETTERS (in BLACK or BLUE ink only) and signed.
Please state name as per your MyKad or Passport.
To avoid delays in your application, it is important that you provide ALL your details clearly including your email address.

Full Name VIRA NUR ALKOMARIA LAELA SAFAATIN

(as in MyKad or Passport)
MyKad No. OR Passport No. : Gender  Male  Female
6474015511000002
Nationality: Race  Malay  Indian
INDONESIA
Country of Birth:
INDONESIA
 Chinese  Others (please specify)
Date of Birth (Day / Month / Year) :
_INDONESIA____________________
NOVEMBER 14𝑡ℎ 2000
Telephone No. (Please include international code): Religion  Islam  Christian
Mobile No. (Please include international code): +6281254715582  Hindu  Buddhist

Email Address: [email protected]  Others (Please specify) ___________________________

(mandatory)
Marital status (Accurate status is required to process International student visa):
Correspondence Address : TARI DEWA-DEWA STREET NO. 31

 Single  Married  Others

City: BONTANG Postcode: 75314

State: INDONESIA Country: INDONESIA

Medical / Special Needs

The information below is used to assist the University in monitoring, supporting and improving service to students with medical disability requirements. Disclosing this information will not
affect your admission to the University.
Do you have a disability, impairment or long term medical condition which may affect your studies?  Yes  No

If yes, please indicate the type(s) of medical condition.

 Hearing  Vision  Learning  Medical mobility  Others (Please specify)

__________________________________________________

© Manipal International University 2018 1

SECTION C PARENT/GUARDIAN DETAILS
Parent / Guardian Particulars Relationship with applicant: FATHER

Father’s/Guardian’s Name: WIJIANTO

(as in MyKad or Passport)
Nationality of Father / Guardian: INDONESIA Gender  Male  Female
Home Address (if this differs from the correspondence address above) : TARI DEWA-DEWA STREET NO. 31

City: BONTANG Postcode: 75314 State: INDONESIA Country: INDONESIA

Telephone No. (Please include international code): Mobile No. (Please include international code): Email Address:
+6281346342599
Mother’s Name: NUNUK NURCHOLIS
(as in MyKad or Passport)
Nationality of Mother: INDONESIA

Home Address (if this differs from the correspondence address above) : TARI DEWA-DEWA STREET NO. 31

City: BONTANG Postcode: 75314 State: INDONESIA Country:

Telephone No. (Please include international code): Mobile No. (Please include international code): Email Address:
+6282149745200

SECTION D ACADEMIC QUALIFICATIONS

Please specify all School/College/Professional qualifications that you have taken from Age 16 and their results. If the qualifications are in languages other than English, please also supply
certified translated copies. The documents must be certified by your current or previous education institution; a Manipal International University registered representative or agent; a Manipal
International University staff member; a solicitor; or commissioner for declaration. Manipal International University reserves the right to refuse documentation on the grounds of incorrect
certification or translation procedures.

Secondary Education

Part 1: SPM / O-Level / or equivalent

Date of completion (Month / Year): 2016 State / Country: INDONESIA
(where you studied)
Name of qualification type (Example: SPM / O-Level): SMP / SPM O

Name of school/institution: SMPN 1 BONTANG

List down the subjects attempted and score / grade achieved:

Subject Score/Grade Subject Score/Grade

GENERAL

Part 2: STPM/A-Level/Pre-U or equivalent (if applicable)

Date of completion (Month / Year): 2019 State / Country: INDONESIA
(where you studied)
Name of qualification type (Example: STPM / A-Level / SAM / CPU): SMA / A LEVEL

Name of school/institution: SMA BUDI UTOMO

Are you currently awaiting results of STPM/A-Level / Pre-U or equivalent?  Yes  No

Expected date of release of results (Month / Year): 2019

List down the subjects attempted and score / grade achieved:

Subject Score/Grade Subject Score/Grade

SCIENCE

© Manipal International University 2018 2

Part 3: Diploma/Undergraduates Studies (if applicable)
Name of Degree / Qualification: TRANING AND EDUCATION FACULTY

Field of Study/Major / Specialisation: BIOLOGY EDUCATION Name of Institution: MULAWARMAN UNIVERSITY

Date of commencement (Month / Year): 2019 Date of completion (Month / Year):

(If you have not completed the programme, please state last Month / Year attended)
State / Country: INDONESIA Did you complete the Diploma /
(where you studied) Undergraduates studies?  Yes  No
Are you currently awaiting results of any Diploma/Undergraduates studies?
 Yes  No
Expected date of release of results (Month / Year):

List down the subject attempted and score / grade achieved:

Subject Score/Grade Subject Score/Grade

BIOLOGY EDUCATION

SECTION E ENGLISH LANGUAGE PROFICIENCY

Please specify the details of any English Language qualifications you have obtained e.g. IELTS or TOEFL.

Test Name : TOEFL TEST

Marks / Grade / Points / Percentage : 460

Year Taken : 2021

SECTION F CREDIT TRANSFER

Do you wish to apply for credit transfer from previous study?  Yes  No

If you request a credit transfer, please include relevant course/module syllabus(es) or curriculum from the university/college at which you pursued your programme. Please take note
that credit transfer would only be considered if the programme and institution are accredited by suitable accreditation authorities in your country.

SECTION G STUDENT VISA / PASS (For non-Malaysian passport holder)

All students with non-Malaysian passports are required to have a student visa/pass to study in Malaysia. Manipal International University will assist in processing the student visa/pass.
We require the following information to process your visa/pass.

Nationality : INDONESIA Place / Country of Birth : INDONESIA

Passport No. : 6474015511000002 Place / Country where Passport was issued: Passport valid until (Day / Month / Year):
(If your country does not issue passports, please state the name of INDONESIA LIFETIME
the travel document you intend to use):

Is either of your parents a Malaysian citizen?  Yes  No

Is either of your parents a Malaysian Permanent Resident?  Yes  No

Have you ever applied to an educational institution in Malaysia?  Yes  No

If YES, please provide the name of the institution.

Have you ever held and obtained a student pass approval from any educational institution in Malaysia previously?
 Yes  No
If YES, please provide the name of the institution

Are you currently in Malaysia?

 Yes  No
If YES, please state your visa / pass type (e.g. student, dependent, social)

When will this visa and/or pass expire? Date (Day / Month / Year):

© Manipal International University 2018 3

 SECTION H OTHER INFORMATION
The information collected in this section will NOT be used for making a decision on your admission.

Do you wish to stay in accommodation provided by Manipal International University?  Yes  No

How did you hear about Manipal International University?

 MIU Website/  Newspaper/Magazine  Road Show/Open Day  Others (Please specify) Friends / Relatives /
Internet
□ Agents

___MULAWARMAN UNIVERSITY______

PRIVACY STATEMENT AND DECLARATION

Privacy Statement

Your personal information collected in this form or otherwise provided in support of your application (“Personal Data”) is processed, retained and used by Manipal International
University to assess your application for entry to a Manipal International University programme, to create an enrollment record on the student database, to prepare statistical analysis
and/or to inform you about your programme and other university programmes/events (collectively “Purpose”). If you do not complete all the questions on this form or do not consent to
the processing of your Personal Data for the Purpose, Manipal International University will not be able to process your enrollment as a student of Manipal International University. Your
Personal Data may be collected from or disclosed to relevant bodies for the verification of your grades, qualifications and/or experience, the processing of your visa application and/or
as otherwise required of Manipal International University by applicable laws or relevant authorities. Manipal International University may also retain and continue to process your
Personal Data after your completion of the programme enrolled for, or otherwise upon you ceasing to be a student of Manipal International University, for archiving purposes, in
relation to Manipal International University’s alumni events and activities and/or to maintain records of your grades, qualifications and/or experience as may be required by Manipal
International University and/or other institutions with whom you enroll for other programmes hereafter. All documents that you provide to Manipal International University become the
property of Manipal International University and will not be returned to you. You have the right to access or correct your Personal Data, or make inquiries or submit any concerns
thereto, by contacting the Admissions Office of Manipal International University at [email protected]

Declaration

I hereby declare that I supply the information on this form and in support of this application on the understanding:
(a) that it may be used for purposes relating to my enrollment as a student, graduation, alumni and career enhancement by members of the academic and administrative staff of
Manipal International University;
(b) that it may be used for purposes external to the University when it is in statistical form where the disclosure is required and in compliance with the Data Protection Act 2010 or
other Laws of Malaysia;
(c) that I have the right to see and correct if necessary the information I have provided;

I warrant that the information on this form, or provided in support of my application, is correct and complete. I acknowledge that the provision of incorrect information or the withholding
of relevant information relating to my application, including academic transcript(s), might invalidate my application and that Manipal International University may withdraw an offer or a
place or cancel my enrollment in consequence thereof. Should Manipal International University determine that I have submitted a false document, I consent to Manipal International
University disclosing this information to other relevant tertiary institutions.

I consent to any educational institution at which I have previously been a student and/or my current or any past employer, providing Manipal International University with information
which that institution or employer holds about me for the purpose of Manipal International University verifying my grades and/or qualifications and experience.

I further confirm and consent to the use by Manipal International University, without charge, my personal information including photographs, images or recordings of the student in
any publicity and/or promotional exercise of Manipal International University, including the publishing of examination results, the award of a prize or scholarship, any achievement,
academic or otherwise. I hereby authorise Manipal International University to release such relevant information to the relevant Alumni Association.

I agree to abide by the statutes, regulations and policies of Manipal International University at all times.

I have read and understood the above conditions, and agree and accept them fully.

WEDNESDAY, AUGUST
24𝑡ℎ 2021
Applicant’s signature Date (Day/Month/Year)

© Manipal International University 2018 4

SECTION J IMPORTANT CHECKLIST

Malaysian Applicants: International Applicants:

□ Application Form □ Application Form
□ 1 x Copy of MyKad □ Application Fee of RM2800 / USD840 (Non Refundable)
□ 1 x Certified true copy of academic transcript/result for SPM/O-Level/ □ 1 x full and clear copies of ALL pages of your passport(s) on A4-sized
or equivalent. paper (2 passport pages per A4 sheet, with NO enlargement)
□ Certified true copy of academic transcript/result/qualification for including the blank pages**.
STPM/A-Level/ Pre-U or equivalent (if applicable). ** It is highly recommended that the passport be valid for the minimum duration of the
□ Credit transfer application with certified true copy of relevant syllabus or
programme. If the passport is expiring within one year from the time an application is not
to be accepted, please apply for a new passport and submit photocopies of ALL pages of
curriculum (if applicable). BOTH passports.
□ 4 x passport-sized most recent colour photographs □ 1 x Certified true copy of academic transcript/result for O-Level/ or
(Blue background - 3.5cm x 5cm - Head Size: 2.5cm x 3cm) equivalent.
□ 1 x Certified Medical Statement (For Section B only) □ 1 x Certified true copy of academic transcript/result/qualification for A-
Level/ Pre-U or equivalent (if applicable).
□ 1 x IELTS score of 6.0
□ Credit transfer application with certified true copy of relevant syllabus
or curriculum (if applicable).
□ 8 x passport-sized most recent colour photographs
(White background - 3.5cm x 5cm – Head / Size: 2.5cm x 3cm).
□ 1 x Health Examination Report
□ 1 x No Objection Certificate (NOC) for applicant from sub-Saharan
countries.
□ 1 x Letter of Eligibility (LOE) for applicant from Nigeria (must be
issued by Federal Ministry of Education, Nigeria)

For International Applicants who have studied in Malaysia before:

□ The original release letter signed by the Chief Executive Officer from last institution of study in Malaysia .
□ Certified true copy of attendance reports from last institution of study in Malaysia.
□ Certified true copy of academic transcripts with information on the grading system* from last institution of study in Malaysia.
□ Certified true copy of Certificate of Completion from last institution of study in Malaysia

BANK DETAILS

Payable to : Manipal International University

Bank Name : Malayan Banking Berhad
Bank Account : 5551 0830 2982
Bank Address : PT 7443, Jalan BBN 1/2F, Bandar Baru Nilai, 71800 Nilai, Negeri Sembilan.
Branch Name : Bandar Baru Nilai
Branch Code : 5510
Swift Code : MBBEMYKL

APPLICATION SUBMISSION
The followings are the steps involved to submit your application.
 Fill in this APPLICATION FOR ADMISSION form
 Attach all required documents. The list of the required documents is available under the heading of IMPORTANT CHECKLIST above.
 The completed APPLICATION FOR ADMISSION form, together with the required documents, should reach the following address:

Admissions Office
Manipal International University (MIU)
No. 1, Persiaran MIU
71800 Nilai
Negeri Sembilan
MALAYSIA

© Manipal International University 2018 5

 FOR OFFICE USE ONLY

BDM OFFICE/STAFF
Counselled by,
□ Documents Complete

□ Documents Incomplete _________________________________

Signature
Specify :
Name:

Date:
CMS - Entered by,

Name: __________________________________ Date: __________________

AGENT
Counselled by,
□ Documents Complete

□ Documents Incomplete _________________________________

Specify : Signature

Name:

Date:

ADMISSION OFFICE
Verified by,
□ Documents Complete

□ Documents Incomplete
_________________________________
Specify :
Signature

Name:
Checked by:
Date: Date:

CMS - Updated by,

Name: __________________________________ Date: __________________

ADMISSION COMMITTEE
Verified by,
□ Firm Offer □ KIV

□ Rejected

© Manipal International University 2018 6

Feedback to Applicant: _________________________________
Signature

Name:

Date:

© Manipal International University 2018 7