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APPLICATION FOR ENROLMENT

Application for: Diploma in Nautical Studies (Deck Cadet)

A) PERSONAL PARTICULARS:

Name (in full): MUHD SYAZLY B. MOHD SALLEH

Address: NO 14 JALAN TUNA,TAMAN SERI TENGGARA

Postcode 34200

Town / City: PARIT BUNTAR

State: Perak

Telephone (Home): 05 - 7173608 Gender: Male

Mobile Phone: 017 - 4325062

Date of Birth (dd/mm/yyyy): 6-Jan-1993 Age: 18

Citizenship: Malaysian Height (cm): 165

Weight (kg): 68

BMI: 24.98

Place of Birth: PERAK NRIC: 930106-08-6051

Religion: Islam Ethnic / Race:Malay

Email Address: kartellohello@ymail.com

B) ACADEMIC REQUIREMENTS:

SPM Exam Result

Year: 2010 Name of school: MRSM LANGKAWI

Subject Level Obtained in SPM

1) Malay Language A

2) English Language A+

3) Mathematics A

4) Physics C+

5) Additional Mathematics C+

C) QUESTIONS:

1) Are you a swimmer?

Answer: Yes

2) Are you wearing visual aids (spectacles or contact lens)?

Answer: Yes

If "Yes", please advise the degree of your visual aid : 75 (must

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5.3) Sports BOWLING

Representing District/State

6) Hobbies:

Answer: SURFING INTERNET

D) PARENTS / GUARDIAN INFORMATION:

Father / Guardian's Name MOHD SALLEH B. MAT DISA

Occupation: RETIRED

Telephone (Home): 05-7173608

Mobile Phone: 017-4325062

E) EMERGENCY CONTACT DETAILS FOR NEXT OF KIN

Name: MOHD SALLEH B. MAT DISA

Address:

NO 14 JALAN TUNA,TAMAN SERI TENGGARA,34200 PARIT BUNTAR,PERAK

Telephone (Home): 05-7173608

Mobile Phone: 019-4750532

Relationship: FATHER

F) OTHERS

1) If you are not successful to get a sponsorship, would you consider paying on your own for this programme?

Answer: No

2) Does your parent work for PETRONAS, MISC Berhad or its subsidiary?

Answer: No

If yes, please state :

Name

Relationship

Department

Designation

G) INSTRUCTIONS TO APPLICANTS

1)

a) Identity Card

b) School Leaving Certificates

c) SPM exam result

2)

3)

4)

H) DECLARATION

(Please select) Agree

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PETRONAS/MISC/Subsidiary (if subsidiary, please state the name of the subsi

. . 2011 and a printed copy is to be brought along on the interview day (i f you are successful) together with certified

photocopies of the following documents:-

Please bring along RM10 for processing fee and RM80 for administrative fee (Total RM90) Postal/Money Order payable to"Malaysian Maritime Academy Sdn. Bhd.".

ONLY shortlisted candidates will be notified for an interview via email.

Successful candidates will be required to attend the Candidate Fitness Assessment (CFA) which will consist of 6 physicaltests. Only candidates who are successful in the CFA test will be offered a placement for the course.

I confirm and certify that the information given aboveare true. I also agree that ALAM has the right to rejectmy application in the event that the particulars givenare found to be untrue.