ALUMNI CARD APPLICATION FORM

INSTRUCTIONS:
1. Please fill in the form with CAPITAL LETTER and attach a recent passport-size
photograph (scanned photo is not acceptable).
2. One application form is meant for one applicant only
3. All completed form must be returned to Alumni and Career Services Division,
Level 1, Rectory building, IIUM, Jalan Gombak, 53100 Kuala Lumpur
4. Please be informed that only those have returned the completed form with original
photograph will receive the Alumni Card.
5. The owner of the Alumni Card will have access to enter the university
and the library, to use the IIUM sport complex facilities, and receive other benefits
and privileges as an IIUM alumnus.

Paste your
photo here

PERSONAL DETAILS
Title
Full Name:
I/C or Passport No :
Nationlity:
Date of Birth:
Current Address:
Tel No:
Email:

Home:

Mobile:

Qualification

EDUCATIONAL BACKGROUND AT IIUM

Kulliyyah

Year of Graduation

Qualification

OTHER EDUCATION INFORMATION

Kulliyyah

Year of Graduation

EMPLOYMENT DETAILS
Position / Job Title:
Company:
Address:
Tel No:
E-mail:

Fax No:
Homepage:
APPLICATION
I would like to participate in the IIUM Commemorative Book 2014
I would like to apply for IIUM Alumni Card with Touch 'N' Go Facilities
SIGNATURE

Singnature : _________________________
Date
: _________________________