PERMOHONAN KEMASUKAN APPLICATION FOR ADMISSION PROSEDUR PERMOHONAN APPLICATION PROCEDURES 1 Isikan dengan jelas, gunakan pen hitam dan HURUF BESAR sahaja. Please use black ink pen in CAPITAL LETTER only. 2 Semua permohonan perlu sampai di Open University Malaysia (OUM) pada atau sebelum tarikh tutup seperti yang diiklankan. All applications must reach OUM on or before the closing date as advertised. 3 Borang permohonan yang telah lengkap hendaklah dihantar kepada: Completed application form must be sent to : Registrar, Open University Malaysia, Level 12B, Menara Dato' Onn, Putra World Trade Centre (PWTC), Jalan Tun Ismail, 50480 Kuala Lumpur. Borang permohonan yang tidak lengkap tidak akan diproses. Incomplete application form will not be processed. SENARAI SEMAK CHECK LIST Borang yang diisi dengan lengkap (semua bahagian). Completed form (all sections). Yuran Proses permohonan sebanyak RM25.00 (bagi Warganegara Malaysia) / RM100.00 (bagi bukan Warganegara) dalam bentuk draf bank/ kiriman wang/ wang pos dibayar kepada UNITEM. Yuran ini tidak akan dikembalikan. Processing fee of RM25.00 (for Malaysian ) / RM100.00 (for non-malaysian) in the form of bank draft / postal order / money order to be made payable to UNITEM. This fee is not refundable. Dua salinan kad pengenalan (bagi Warganegara Malaysia) / salinan pasport (bagi bukan warganegara Malaysia) dan salinan sijil-sijil dan transkrip akademik yang telah disahkan. Two copies of NRIC (for Malaysian) / passport (for non-malaysian) and academic qualifications and transcript duly certified. 4. Kad Pemberitahuan yang dilengkapkan dan ditampal dengan setem RM0.30 (untuk warganegara sahaja). Completed acknowledgement card to be attached with a RM0.30 stamp (for Malaysian only).
MALAYSIA Jantina (Sex) Lelaki (Male) Perempuan (Female) Taraf Perkahwinan (Marital Status) Belum Berkahwin (Single) Berkahwin (Married) Kecacatan (Disability)
Mata Pelajaran (Subject) SILA KEPILKAN MAKLUMAT TAMBAHAN JIKA PERLU (Please attach additional information if necessary) Keputusan (Result) Gred (Grade) Mata Pelajaran (Subject) Keputusan (Result) Gred (Grade) Mata Pelajaran (Subject) Keputusan (Result) Gred (Grade) LCE/SRP/PMR 4. 5. 6. 7. SPM / SPMV / O - Level 4. 5. 6. 7. STPM / STP / HSC / A-Level 4. 5. 8. 8. 9. 9. 10. 1 D. MAKLUMAT PEKERJAAN (EMPLOYMENT DETAILS) Status Pekerjaan (Employment Status) Pendapatan Sebulan (Monthly income) Kategori Jawatan Sekarang (Current Position Category) Sektor Pekerjaan (Industry) Organisasi (Organisation) Jawatan (Position) Tempoh (Duration) Tahun (Year) Bulan (Month) Pengetahuan / Kemahiran Yang Diperolehi (Knowledge / Skill(s) Acquired) Contoh Example : Sila isikan kod pengetahuan / kemahiran yang diperolehi daripada pekerjaan sekarang / terdahulu - seperti sekiranya anda bekerja sebagai pembantu kewangan, nyatakan pengetahuan / kemahiran matematik / perakaunan yang diperolehi. (Fill in coding for the knowledge / skill(s) acquired from present / previous job - e.g. if you have worked as a financial assistant, specify the knowledge /skill in mathematics / accounts obtained).
F. KEMAHIRAN BAHASA (LANGUAGES) Bahasa (Language) Pertuturan (Spoken) Penulisan (Written) a) Bahasa Malaysia (Malay) b) Bahasa Inggeris (English) c) Lain-lain (Sila nyatakan) Others (Please specify) i) ii) Note: Foreign applicants are requested to submit their IELTS or TOEFL scores Nama Ujian: (Name of Test) Tahun Ujian diambil: (Year Taken) Markah (Score) G. PINJAMAN KEWANGAN (FINANCIAL SUPPORT) Bagaimana anda bercadang untuk membiayai pengajian anda? (Sila Tandakan) (How do you plan to support your graduate studies?) (Please tick) Pinjaman Peribadi (Personal Finance) Biasiswa (Scholarship) Lain-lain (Others) Sila nyatakan: (Please specify:) Dari sumber manakah anda tahu mengenai OUM (Boleh pilih lebih dari satu) From which source do you know about OUM (May choose more than one) Kawan (Friends) Prebiu (Preview) Ahli Keluarga (Family Members) Pameran (Exhibition) Surat Khabar (Newspapers) Papan Iklan (Outdoor Advertising) Majalah (Magazines) Pelajar OUM (OUM s Students) Radio/Televisyen (Radio/Television) Lain-lain (Others) Sebab anda memilih OUM (Boleh pilih lebih dari satu) Why do you chose OUM (May choose more than one) Sistem yang fleksibel (Flexible system) Boleh belajar sambil berkerja (Can study and work at the same time) Kemudahan yang disediakan (Facilities provided) Pengiktirafan dari LAN (Accredited by LAN) Tiada pilihan lain (No other choice) Yuran yang berpatutan (Affordable fees) H. I 3
UNTUK DIISI OLEH PEMOHON PROGAM SARJANA MUDA SAINS KEJURURAWATAN SAHAJA (TO BE COMPLETED BY APPLICANT FOR BACHELOR OF NURSING SCIENCE PROGRAMME ONLY) No. Pendafataran Lembaga Jururawat Malaysia Registration No.With Nursing Board Malaysia Lampirkan salinan Sijil Pengamalan Tahunan yang disahkan Please attach a certified copy of Certificate of Annual Practice A. BUTIR-BUTIR PERIBADI (PERSONAL PARTICULARS) Nama Penuh (Full Name) Alamat Hospital Bertugas (Address of Hospital) Poskod Poscode Bandar Town Negeri State No.Tel (Rumah) / Tel. (House) No. Tel (Pejabat) / Tel. (Office) No. Tel (Bimbit) / Tel. (Mobile) B. BIDANG PENGKHUSUSAN LATIHAN PRAKTIKAL (SILA PILIH 3 BIDANG SAHAJA) SPECIALIZATION FOR CLINICAL (PLEASE SELECT 3 AREAS ONLY) Kepakaran 1 CRITICAL CARE NURSING Atau (CLINICAL PRACTICE 11) TRAUMA AND EMERGENCY NURSING Kepakaran 1 (CLINICAL PRACTICE 12) Kepakaran 1 (CLINICAL PRACTICE 13) Atau Atau PAEDIATRICS NURSING MENTAL HEALTH NURSING ONCOLOGY NURSING RENAL NURSING C. HOSPITAL UNTUK LATIHAN KLINIKAL (TANDAKAN ) / HOSPITAL FOR CLINICAL PRACTICE (TICK ) 1 Hospital Kangar, Perlis 2 Hospital Alor Setar, Kedah 3 Hospital Sungai Petani, Kedah 4 Hospital Seberang Jaya, Pulau Pinang 5 Hospital Pulau Pinang, Pulau Pinang 6 Hospital Taiping, Perak 7 Hospital Ipoh, Perak 8 Hospital Tengku Ampuan Rahimah, Klang, Selangor 9 Hospital Serdang, Selangor 10 Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan 11 Hospital Kuala Terengganu, Terengganu 12 Hospital Tengku Ampuan Afzan, Pahang 13 Hospital Sultanah Aminah, Johor Bahru, Johor 14 Hospital Batu Pahat, Johor 15 Hospital Seremban, Negeri Sembilan 16 Hospital Sibu, Sarawak 17 Hospital Miri, Sarawak 18 Hospital Umum, Sarawak 19 Hospital Quenn Elizabeth, Sabah 20 Hospital Likas, Sabah 21 Hospital Sandakan, Sabah 22 Hospital Universiti Kebangsaan Malaysia (HUKM) 23 Hospital Universiti Sains Malaysia (HUSM) 24 Pusat Perubatan Universiti Malaya (PPUM)