Axismatics Professional Institute(JPWP486)	No. 12B-07, 14th floor, Wisma Zelan, No. 1, Jalan Tasik Permaisuri 2, Bandar Tun Razak,  56000 Kuala Lumpur. Tel: (603)- 9173 5686 / 9173 6082   Fax (603)- 9173 8782 Website: http://www.axismatics.edu.my Email: axisma@tm.net.my
Please fill in all sections. An application fee* (non-refundable) is payable on submission  of this form. The payment can be made in the form of a cheque / bank-draft to “Axismatics Professional Institute” or through our CIMB Bank’s account no. 12700000280058, or Public Bank Account: 3134240309 * Application & Registration fees:         - RM150.00
1. Section I : Personal details Name:___________________________________ Male ___ Female ___ I.C. No:__________________________________ Date of Birth: ____/____/____ (day/month/year) Present Address: _________________________________________________________________________ ________________________________________________________________________________________ Tel / HP : _________________ Fax: ____________ Email: __________________   Name of Father: ___________________________ Name of Mother: ______________________________ Hometown Address: ________________________________________________________________________ __________________________________________________________________________________________ Tel / HP : _____________ Fax: ____________ Email: __________________
2. Section II: Application Information Name of Course :  __________________________________________________ Commencement Date (Month/Year) : ____________________________________  Are you applying for / getting a Scholarship: Yes ___ No ___ *  If “Yes”, who will be your scholarship provider? __________________________________

3. Section III : Educational Qualifications

Please give details of all your secondary and other post-secondary education. You must attach certified copies of your academic results.

Name of School

Name of Qualification or Examination (eg. SPM, UEC, O-Level, etc.)

Years attended (eg. 1992 to 1998)

Grade/Result (eg. 5As 2Bs)

English Language Proficiency

English test taken (eg. SPM, 1119, TOEFL, etc.):________________________________________

Date taken (day/month/year) : ___________________ Result: _________________________________

4. Section IV : How did you know about Axismatics Professional Institute?

Please ( / ) the suitable box(s) in front of each category.

___  Media or Newspaper advertisement Name of Publication: ___________________________

  ___ Education Exhibition Date & City: ___________________________

 ___ Teacher or counsellor School: _____________________________________

 ___ Education Agent Name: ______________________________________

 ___ Friends Are they students of Axismatics? Yes ___ No ___

___ Others : ______________

5. Section V : Declaration

I declare that to the best of my knowledge the information given in this application and the supporting documents are correct and complete. I agree to present the original copies of my academic results and all relevant documents to Axismatics for further verification if required. I acknowledge that the provision of any incorrect information or documentation or withholding of any information or documentation in relation to my application may result in cancellation of any offer of enrolment by Axismatics. I also understand that Axismatics reserves the absolute right to discontinue or alter any course, subject, fees, entry requirements, staffing or other arrangements without prior notice.

Applicant’s signature: ________________________ Date of application: _____________

Name: _____________________________________