Direct Application Form - 2016 ENTRY
Course Title
Campus
: BSc (Honours) Biomedical Sciences 2+1 Programme with Newcastle University, UK
: Newcastle University Medicine Malaysia, Johor, Malaysia
Application Number: (Office use only)
1. Personal Details
Title:
 Mr  Mrs Miss Ms Other
Name as it appears on Identity Card/Passport:
IC Number (Malaysian citizens ONLY)
Passport Number:
Student Number: (Office use only)
2. Additional
Country of Birth:
Race:
Religion:
Nationality: (Please state if you have dual
nationality)
1.
2.
Country of usual permanent residence:
Name you wish to be known by:
Emergency contact details:
Name:
Home address:
Telephone number:
Address:
Contact telephone numbers:
Home:
Mobile/Handphone:
_______________________________________
Do you have a physical or mental disability or any
special needs:
 Yes  No
If yes, please provide details:
Email address:
Gender:
 Female  Male
Date of Birth: (example 27/05/1985)
Day
Month
Year
NUMed/ADMS-BMS-APP/003
________________________________________
Payment of fees (tick as appropriate)
Yourself/Family
 Your employer (please specify)
 Sponsor/please specify
3. Education and Qualifications
School or College Attended
School or College
Month
To
Year
From
Month
Year
Full Time
Qualifications completed
If you have already achieved the qualifications and grades required, send a certified copy of the
qualification documents with your application.
Date of
examination or
awards
Month
Year
Awarding
Body
NUMed/ADMS-BMS-APP/003
Subject
Level of
Qual.
Result
Grade
Qualifications you are still studying
You will need to provide information on the grade (forecast results) your school/college expect you to
achieve.
Date of
examination or
awards
Month
Year
Awarding
Body
Subject
Level of
Qual.
Result
Grade
English Language Qualification
Qualification (e.g. IELTS,
TOEFL, MUET)
Date
Overall
Grade
Spoken
Written
Reading
4. Criminal Convictions
If you have any criminal convictions, please tick this box and provide details below. 
NUMed/ADMS-BMS-APP/003
Listening
5. Reference – Enter the contact details of the person you have asked to provide a certified
reference.
Name of referee:
Post/Occupation/Relationship:
Name and Address of School /College:
Telephone:
Email:
What you must tell the person writing your reference:

The reference must be certified by the school or college.

The following questions must be covered in the reference:
o
Name of applicant reference is supporting.
o
Full name of Referee.
o
Occupation of Referee.







How long and in what capacity have you known the applicant?
Do you know of any reason why the applicant should not be enrolled in this University?
Does this applicant have any criminal convictions that you are aware of?
Provide details of examination results or predicted examination results for the applicant.
If the applicant’s first language is not English, please comment on his/her level of competence by grading
each of the following areas as either Excellent; Good; Fair; or Poor.
o
Written
o
Listening
o
Comprehension
o
Spoken
o
Reading
Provide comments on the academic suitability of the applicant for the medicine programme and any factors
that may affect their ability to complete the programme.
The reference must be received by Newcastle University Medicine Malaysia as soon as possible.
The reference must be sent to: admissions@newcastle.edu.my.
Or by post to:
Newcastle University Medicine Malaysia
No 1, Jalan Sarjana 1
Kota Ilmu, EduCity@Iskandar
79200 Nusajaya, Johor
Malaysia
NUMed/ADMS-BMS-APP/003
6. Declaration
 I warrant that the information on this form, or provided in support of my application, is accurate and
complete. I acknowledge that the provision of incorrect information or the withholding of relevant
information relating to my application might invalidate my application and that the University may
withdraw an offer of a place or cancel my enrolment in consequence.
Should the University determine that I have submitted a false document, consent to the University
disclosing this information to other relevant institutions.
 I consent to any educational institution at which I have previously been a student and/or my current
or any past employer, providing Newcastle University Medicine Malaysia with information which that
institution or employer holds about me for the purpose of Newcastle University Medicine Malaysia
verifying my grades and/or qualifications and experience.
I accept that information provided by me will be retained by Newcastle University Medicine Malaysia ,
and will be made available to Newcastle University and the federal state government agencies, pursuant
to obligations under the Private Higher Education Act 1996 (Act 555).
I agree to abide by the statutes, regulations and policies of Newcastle University.
I give consent to the processing of my data by Newcastle University, which I understand will be in
accordance with the requirements of the Data Protection Act 1998.
I have read and understood the above conditions and accept them fully.
Applicants Name:
Date:
7. Checklist (Please attached the following documents with your email application)
 Copy of IC (Malaysian applicant)/Passport (International applicant).
 Copy of SPM result (Malaysian applicant)/Copy of O Level/High School result (International
applicant).
 Copy of IELTS, TOEFL, or MUET, etc.
 Pre-U forecast result from college/institution (applicable to applicant that applies without final
result).
 Copy of Pre-U final result from college/institution.
 Written reference from your referee (your referee can also send the reference after you have
submitted your application form).
NUMed/ADMS-BMS-APP/003
8. Where did you hear about NUMed?
 Parent/friend
 College/School
 Education Fair
Please state which Fair_________________________
 Internet search
 Facebook
 Newspaper advert or article
 Words of mouth
 Other (please state_____________________
Decision by Admissions Team (Office use only)
Offer Conditions:
Application Received:
Qualification Documents verified:
Reference Received:
Complete and email this form to admissions@newcastle.edu.my
NUMed/ADMS-BMS-APP/003