誓 約 書

法 政 大 学 総 長 殿

私は、春季短期英語研修 in マレーシアに参加するにあたり、下記事項を遵守することを誓

約いたします。

記

１．留学中は、留学先の大学の規則を守り、本学学生の誇りをもって行動すること。

２．派遣期間中は学業に専念すること

３．留学期間を全うして帰国すること。

４．留学中途の無断帰国をしないこと。また、休暇中などに留学先を離れるときは必ず事

前に行き先、期間、連絡先を国際交流センターに連絡し、帰宅後は速やかに帰宅連絡

をいれること。危険が予測される地域には立ち寄らないこと。

５．移動に当たっては団体行動となることから、集合時刻・場所を守り、身勝手な行動は

しないこと。

６．留学中の疾病および事故等は、自己の責任で処理すること。また、災害傷害、その他

の事故等の補償を大学に要求しないこと。留学期間中は大学の指定する海外旅行傷害

保険へ加入すること。

７．留学中は、車の運転はしないこと。

８．留学中は、日本国および留学先国の法令・慣行を遵守すること。

９．留学期間終了後、大学が指定した日時に帰国すること。

１０． 世界情勢の変化などにより留学が取り止めになる場合があることを理解し、取り

止めとなった場合にも異議を申し立てないこと。

１１． 留学中において、外務省等の危険情報発出等に連動し、大学が「帰国勧告」を行

った場合、ただちに大学の命に従い帰国すること。その際の経費は本人が負担するこ

と。

2014年 月 日

所 属 学部 学科 年

本人氏名 印

TEL（固定） TEL（携帯）

氏名：

TEL（固定） TEL（携帯）

e-mail：

※個人情報の取り扱いについて

法政大学国際交流センター

ＴＯＥＦＬ-iBT

年学部

IELTS(Academic module)

点

月 日

学生証番号

国籍

本申込書に記載の個人情報については、下記の目的に使用します。1.本研修や帰国後アンケート及びそれらに関連する事務手続きのため。2.大学経由で申込の海外旅行傷害保険の申込手続きのため。

特記事項(健康状態等)

※特にない場合には「特になし」と記入

海外旅行傷害保険

□　留学期間中をカバーする海外旅行傷害保険を申し込みます。（必須）　　　（費用：6,950円）

海外渡航経験

□有

□無

ＴＯＥＦＬ-PBT

点

点

連絡先（自宅）

e-mail (PC)：

〒

e-mail (携帯)：

英語能力

応募目的（複数可）

□派遣留学応募準備　□海外大学院進学準備　□英語各種試験でのスコア向上

□留学生との交流　□海外文化体験　□大学主催プログラム　□留学先国に興味

□その他（　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　）

（　□1回　　　□2～5回　　　□5回以上　　　□海外に居住経験有　）

連絡先（保護者）

〒

本人との関係：

ＴＯＥＩＣ

点

その他（　　　　　　　　　　　　　　　　　　　　　）

該当するものがなければ記入不要

春季短期英語研修 in マレーシア　申込書

(ふりがな)

氏名

提出締切：1月27日（月）

性別 □男 □女

学部学科学年

生年月日 西暦 年

学科

Level of study:

PART B : COURSE APPLIED FOR

Course name: Specialism (if applicable):

Diploma Part 1

Diploma Part 2

Intake date (mm/yy):

Mode of study: Full - time Part - time Degree Foundation

Degree Level 1 Degree Level 3

For office use only

Student Number:

Programme code:

Name (as per IC / Passport):

PART A : PERSONAL DETAILS

Title: Mr Ms Mrs Other

IC Number (For Malaysian Students only):

Gender: Male Female

Passport Number (For International Students only): Nationality:

Date of birth (dd/mm/yy):

APPLICATION FORM(Undergraduate only)

International Country

Malaysian

Race:

Religion:

Place of birth:

Please complete and return this form to: Asia Pacific University of Technology & Innovation (APU) Technology Park Malaysia, Bukit Jalil, 57000 Kuala Lumpur, Malaysia Tel : 603-8996 1000 Fax: 603-8996 1001 Email: info@apu.edu.my

Mailing Address

City / State: Postcode: Country:

Contact number:

Tel Mobile

Parent / Guardian:

Contact number:

Email (please write clearly):

Tel Mobile

Contact person in Case of Emergency:

Contact number:

Tel Mobile

Relationship to the student:

Employer’s Name (if applicable for Part -Time students): Employer’s address:

Employer’s Contact number:

Tel Mobile

Email (please write clearly):

Degree Level 2

Marital Status:

Subject Completed Result For office use only

LAN 1001 BM (A)

LAN 1003 MLY

LAN 1004 ISL

LAN 1005 MO

Bahasa Kebangsaan (A) (Malaysian students without Credit in SPM BM)

Malaysian Studies (All Students)

Islamic Studies (Only for Malaysian Muslim Students)

MQA Compulsory Subjects completed at (if applicable):

In order to be considered for exemption for MQA Compulsory Subjects, please submit certified MQA Academic result & syllabus from your previous Institution together with this form. Declaration:

I, declare that all the particulars provided in this form are complete and correct. I have also understood that I need to complete MQA subjects in order to graduate from APU. Signature : Date :

PART C : ACADEMIC BACKGROUND (from highest to lowest)

Actual Forecast Qualification: Name of School / College / University: Year completed: Result:

PART D : MEDICAL DISCLOSURE

Do you have any medical condition that requires the attention of the University? If yes, please indicate below:

Allergies Anaemia Asthma Heart Disease Colour Blindness Epilepsy

Others (please give details):

Note (for International Students Only):

1. It is compulsory for all international students to purchase a health care plan and keep it valid throughout your academic study at APU. We will assist you with this upon your arrival in Malaysia.

2. Students from Yellow Fever Endemic Zones and other affected areas are required to have an International Health Certificate showing Yellow Fever Vaccination.

Please list in chronological order all secondary and tertiary studies completed. Please attach a copy of your certificates and the transcripts of all results obtained for your highest level of study, plus a certified translation if the originals are not in English.

PART E : MQA COMPULSORY SUBJECT DETAILS (FOR MALAYSIAN APPLICANTS ONLY)

The Ministry of Higher Education requires students to take the following subjects during the course of their studies. If you have sat for and passed / completed, whilst as a student in Malaysia, any of the following compulsory subjects at Pre-University or tertiary level, please mark in the appropriate box(es).

For Office Use Only

Exemption: Remarks : Signature : Date :

Approved Rejected

Other

Not Completed

Moral Studies (Only for Malaysian Non-Muslim Students)

Name of the institution

PART F : PERSONAL STATEMENT Please give your reasons for choosing us to further your study. (Continue on a separate sheet if required)

PART I : ACCOMMODATION & ARRIVAL ARRANGEMENTS

PART G : ENGLISH LANGUAGE PROFICIENCY

Name of Test / Examination: Name of School / College/ University: Date (to be) taken: Results (if known):

English was the language of instruction in my previous completed studies Yes No

I hold / have completed the English language qualification (s) listed below:

PART H : MALAYSIAN IMMIGRATION INFORMATION

Are you currently holding any type of Malaysian Immigration Pass / Visa?

Yes No

Social Visit Diplomatic Student Dependent If yes, type of Immigration Pass / Visa:

Expiry date of immigration Pass / Visa held : (dd/mm/yy)

(Those transferring from other Institutions / colleges / Universities in Malaysia and holding a Student Pass / Visa or Dependent Pass will need to provide the School Leaving Certificate / Testimonial, Release Letter, Results and Attendance Report / Letter from this institution)

If you are a student / former student of any Institution / College / University in Malaysia, please fill in the following:

Course:

Institution / College / University:

Duration studied there: year(s)

Do you require APU to arrange your accommodation?

Yes No, I will arrange for my own accommodation

If yes, please fill up the Accommodation Application Form.

Yes No

** Note : 1. This service is not available to students who are on a Social Visit Pass and who enter Malaysia via ports of entry other than Kuala Lumpur

International Airport (KLIA).

2. Notice for airport pick-up must be given at least 7 working days in advance by filling in and sending the arrival details form back to APU prior to arrival.

Do you wish for APU to arrange to pick you up from the airport? (only applicable for new applicants)**

PART G TO PART J : FOR INTERNATIONAL APPLICANTS ONLY

PART J : CONDITIONS FOR ENROLMENT

Registered by: Date:

FOR OFFICE USE ONLY : COURSE FEE PAYMENT DETAILS

Payment upon registration:

2. Course Fee

3. Library Deposit (refundable)

4. Library Fee

5. Engineering Laboratory Deposit (refundable)

6. Student ID Card

Total fees paid upon registration

1. Registration Fee

7. Application Fees (for International students only)

8. Personal Bond (for International students only)

10. Others ______________________________

9. Health Care Plan (for International students only)

Payment option : Full payment

Mode of payment : Cash Cheque Others (upon registration)

Note: 1. Payment by cheque / Bank Draft is to be made payable to:

Asia Pacific UCTI SDN BHD.

2. For payments made by cheque, please indicate:

Bank :

Cheque No :

Installment - Semester

Installment - Monthly (for Malaysian Applicants only)

Data input in GIMS by: Date:

Registration checked & approved by: Date:

PART L : DECLARATION

1. I declare that all the particulars provided in this form are complete and correct.

2. I agree to abide by APU’s Professional Code of Conduct.

3. I have also read and understood APU’s refund policy which is stated here and in the Fee Guide.

4. I undertake to ensure that all fees are paid by the specified due dates, and otherwise agree to pay any late payment and / or administrative charges incurred after the due dates. If the fees are not received by 21 days from the due date, I understand that I may not be allowed to use the facilities at APU.

Signature : Date :

PART K : IMPORTANT CHECKLIST

Completed all sections of this application form (where applicable)

Attached certified certificates / testimonials

Attached certified Forecast / Trial results

Attached photocopy of IC / Passport (1 copy)

Malaysian Applicants

Attached certified copies of secondary or secondary vocational school results / transcripts from high school or/and other higher institutions of learning (if in another language, please provide a certified translation)

Completed all sections of this application form (where applicable)

International Applicants

4 passport sized photographs

Visa processing fees and administrative charges

Attached 2 photocopies of main pages (details/picture) of your passport

AF/APU/August 12/V1

1. Fees for the academic year are as set out in the fee schedule.

2. Payment by crossed cheque, money order or bank draft is to be made payable to Asia Pacific UCTI SDN BHD.

3. The Visa processing fees and administrative charges for International students will not be refunded in the event the student withdraws from the programme for any reason.

4. Fee payments made are not refundable except if your visa is refused by Immigration. In such cases, your fee payment will be refunded after the deduction for Visa processing and administrative charges paid by APU. The fee payment will not be refunded once you obtain a visa to study in Malaysia or after a course has commenced.

5. Students must abide by all academic, administrative and examination rules and regulations and policies at APU.

6. APU reserves the right to use your personal information in order to carry out its responsibilities in your personal and / or academic interest as a student of APU. The scope of usage of this information may include the publishing of good examination results, the award of a prize or scholarship or otherwise.

Health examination report