Course Title : Foundation Certificate in Biological & Biomedical Sciences with Newcastle University, UK
Campus : Newcastle University Medicine Malaysia, Johor, Malaysia
Application Number: (Office use only)
Student Number: (Office use only)
Title:
 Mr  Mrs  Miss  Ms  Other
Name as it appears on Identity Card/Passport:
IC Number (Malaysian citizens ONLY)
Passport Number:
Name you wish to be known by:
Home address:
Contact telephone numbers:
Home:
Mobile/Handphone:
Email address:
Gender:
 Female  Male
Date of Birth: (example 27/05/1985)
Day Month Year
NUMed/ADMS-FIS-APP
Country of Birth:
Race:
Religion:
Nationality: (Please state if you have dual nationality)
1.
2.
Country of usual permanent residence:
Emergency contact details:
Name:
Telephone number:
Address:
_______________________________________
Do you have a physical or mental disability or any special needs:
 Yes  No
If yes, please provide details:
________________________________________
Payment of fees (tick as appropriate)
 Yourself/Family
 Your employer (please specify)
 Sponsor/please specify

Month
Year
Month Year
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
Subject Level of
Qual.
You will need to provide information on the grade (forecast results) your school/college expect you to achieve.
Result
Grade
Date of examination or awards
Month Year Awarding
Body
Subject Level of
Qual.
Result
Grade
NUMed/ADMS-FIS-APP

Qualification (e.g. IELTS,
TOEFL, MUET)
Date Overall
Grade
Spoken Written Reading Listening
Note: You do not have to have an English language qualification at the time of applying but you must have achieved the required level by the time you begin the programme .
 MBBS
 BSc (Honours) Biomedical Science
 Either
NUMed/ADMS-FIS-APP

If you have any criminal convictions, please tick this box and provide details below. 
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
NUMed/ADMS-FIS-APP

 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 Iskandar Puteri, Johor
Malaysia
 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:
NUMed/ADMS-FIS-APP

 Copy of IC (Malaysian applicant) / Passport (International applicant).
 Copy of SPM forecast result (Malaysian applicant) / Copy of O Level / High School forecast result
(International applicant). This is applicable to applicant that applies without final result.
 Copy of SPM result (Malaysian applicant) / Copy of O Level / High School result (International applicant).
 Copy of IELTS.
 Written reference from your referee (your referee can also send the reference after you have submitted your application form).
 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)
Application Received:
Reference Received:
Offer Conditions:
Qualification Documents verified:
NUMed/ADMS-FIS-APP