Intake Form KS

APPLICATION FOR PRE-ADMISSION

APPLICATION DETAILS

Name ( AS IN PASSPORT ) *

IC / Passport No *

Race

Date of birth *

Marital Status : *

Single

Married

Divorced

Gender : *

Male

Female

Religion *

Country of birth *

Nationality *

Phone (Mobile) *

Phone (House) *

Permanent mailing address *

City *

Postcode *

State *

Country *

Email *

HEALTH INFORMATION

Do you have a medical condition that require special attention? If so, Please state :

PARENT / GUARDIAN / NEXT OF KIN DETAILS

Name of Parent / Guardian / Next of Kin *

Relationship *

Permanent mailing address *

City *

Postcode *

State *

Country *

Country Code *

Area Code *

Telephone
Number *

Email *

Occupation *

Office Address *

State *

Country *

Home Tel. No *

Mobile No. *

Parents Salary (Please insert with currency). *

ACADEMIC QUALIFICATION

Highest Qualification *

Year of Completetion *

Secondary School *

Secondary School Address *

School Tel. No *

Fax No. *

Detailed Result: (A copy or the official result/transript must be attached together with this application).

NO.	SUBJECT	GRADE/SCORE
1.*
2.*
3.*
4.*
5.*
6.*
7.*
8.*
9.
10.
11.
12.
13.
14.

EXTRA-CURRICULAR ACTIVITIES

NO.	Games/Societies/Club/Uniform Bodies	Position Hold	Level	Year	Highest Achievements
1.
2.
3.
4.
5.
6.
7.

PROGRAM APPLIED

Program: *

Do you require any scholarshp : *

Yes

Agent:

Note: Please contact us via email: cis@kolejspace.edu.my
or call us at +60327722514 for any inquiries