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Online Application Form for *Session : Year :
Programmed of Choice :
* First Choice :
* Second Choice :
* Third Choice :


* please fill in the required information


Personal Details

* Name : Religion :  
* Identity Card :
(ex. 770407-03-9876) 		* Date of birth :
(ex. 12/31/1999) 
Place of Issue : Country :
* Citizenship / Nationality : * Sex :
Race : Marital status :
* Postal address : Permanent address :
       
       
* Postcode : Postcode :
* State : State :
* Telephone :
(ex. +603 55136688)		 Telephone :
(ex. +603 55136688)
* E-mail :      

  Contact person in case of emergency .
Parents / Guardian's name : Name :
Identity card no :
(ex. 770407-03-9876) 		Address  
Citizenship  / Nationality :    
Occupation :    
Monthly income : RM (700.00) Postcode :
No of dependent : State :
Address : Relation :
    Telephone   (ex. +603 55136688)
     
Postcode :
State :
Telephone :
(ex. +603 55136688)		      


Qualification Completed & Held


* School :
Academic Qualifications: SPM / SPMV /O Level
 * Year :     Aggregate :
Subject/Grade
Bahasa Melayu : Sains :  
Ekonomi Asas : Lukisan Kejuruteraan :  
Perdagangan : Bahasa Inggeris :
Matematik Tambahan : Pendidikan Seni :  
Kejuruteraan Jentera :   Prinsip Akaun :
Geografi : Fizik :  
Kejuruteraan Awam :   Matematik :
Kimia : Kejuruteraan Elektrik & Elektronik :
Sejarah :   Biologi :
Teknologi Kejuruteraan : Pengetahuan Agama Islam :  
Sains Tambahan : English for Science & Technology :
 
Others
:
:
:


Academic Qualifications: STPM (Grading scheme for STPM starting 2003: Principle passes are A+,A,A-,B+,B,B-,C+,C)
 
School :
 
Year :        Principle :        Subsidiary :
 
Subject/Grade
 
General Paper : Chemistry :  
English :   Biology :
History : Mathematics :
Geography : Advance Mathematics :
Economic :   Mathematics S :  
Business Study :   Bahasa Melayu :
Pengkomputeran : Syariah :
Physic : Bahasa Arab :
 


  Universities/Colleges Qualification Certificate Programme Performance
Duration of study (months)
 Graduation year
1.
2.
 

Employment Details (if applicable)

 
 Year Occupation Level Employer
1.
2.

Sponsor Particular


Particulars of the applicant's sponsor (person / organisation responsible for payment of all fees).
 
Name
 :   IC/Passport Number :
Correspondence Address
:   Relationship :
:   Telephone :
:        
Postcode
 :        

Hostel Accomodation

* Do you want hostel accomodation ?
Yes No


Medical History

Please indicate if you have ever suffered from or experienced or received treatment for the following diseases and condition :
Bronchial Asthma Yes No Diabetes Mellitus Yes No Psychiatric Illness Yes No
Hypertension Yes No Heart Diseases Yes No HIV / AIDS Yes No
Hearing Problem Yes No Kidney Diseases Yes No Others


Submit Application Form


I declare the information provided in connection with this application is true and correct. I understand that PTPL 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 PTPL rules and regulations.

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