01(A)/GMI-SAS-AR

GERMAN-MALAYSIAN INSTITUTE DIPLOMA

PROGRAM
No. 119 Jalan 7/91, Taman Shamelin Perkasa Application Form
3½ Miles Cheras, 56100 Kuala Lumpur
Tel: (603) 9286 1706 Fax: (603) 9282 2603 http://www.gmi.edu.my

Instruction / Arahan:
Please fill & tick (√) accordingly and clearly / Sila isi & tandakan (√) pada ruang yang sesuai dengan jelas.

A. PERSONAL DETAILS | BUTIRAN PERIBADI

Name / Nama

Identity Card No. / Date of Birth / Photo

No. Kad Pengenalan Tarikh Lahir

Nationality / Birth Place /

Kewarganegaraan Tempat Lahir

Marital Status / ‰ Single/Bujang ‰ Male/Lelaki

‰ Married/Berkahwin
Gender / Jantina ‰ Female/Perempuan
Status Perkahwinan

‰ Malay/Melayu ‰ Peribumi Sabah/ ‰ Others/Lain-lain:

Race / Bangsa ‰ Chinese/Cina Sarawak
‰ Indian/India

Postal Address /
Alamat Surat-
menyurat

Postcode: State/Negeri:

Telephone / Telefon Home/Rumah: Mobile/Bimbit:

B. COURSE PREFERENCE | PILIHAN KURSUS

Please indicate your choice of preference (by number) in the box provided / Sila nyatakan keutamaan pilihan anda (dengan nombor) di
dalam kotak yang disediakan.

TDT Diploma in Production Technology (Tool & Die Technology) OFFICE USE /
KEGUNAAN
PEJABAT
MOT Diploma in Production Technology (Mould Technology)
‰ Completed
PDM Diploma in Product Design & Manufacturing ‰ Final Sem

‰ SPM/SPMV
CNC Diploma in CNC Precision Technology ‰ STPM
‰ Metrics
EIT Diploma in Industrial Electronics (Electronics & Information Technology) ‰ Pre-Dip.

‰ IKM -
MEC Diploma in Industrial Electronics (Mechatronics)
‰ ILP -
‰ POLI -
PIC Diploma in Industrial Electronics (Process Instrumentation & Control) ‰ SKM2 -
‰
NWS Diploma in Network Security
‰ ELG
‰ NELG

CK:

‰ INTVW
‰ NINTVW

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C. ACADEMIC DETAILS | BUTIRAN AKADEMIK

SPM/SPMV (Compulsory to be filled / Wajib dilengkapkan)

Year of Sitting / Tahun Menduduki

School Name / Nama Sekolah

State/Negeri:

‰ Maktab Rendah Sains MARA (MRSM) ‰ Sek. Men. Vokasional

School Category /
‰ Sek. Berasrama Penuh (SBP) ‰ Sek. Men. Keb. Agama
Kategori Sekolah ‰ Sek. Men. Teknik ‰ Sek. Menengah

No Subject / Matapelajaran Grade No Subject / Matapelajaran Grade

1 Bahasa Melayu 7
2 Bahasa Inggeris 8
3 Matematik 9
4 10
5 11
6 12
*Please attach a certified copy of your SPM/SPMV result / Sila sertakan salinan keputusan SPM/SPMV anda yang telah disahkan.

Technical Certificate / Sijil Teknikal

Institution / Institut ‰ Institut Kemahiran MARA (IKM) ‰ Others/Lain-lain:

‰ Institut Latihan Perindustrian (ILP)
‰ Politeknik

Branch / Cawangan

Course / Kursus

Award / Anugerah ‰ Sijil Teknikal/Teknologi ‰ Sijil Kemahiran Malaysia (SKM) – Tahap:

Starts/Mula Ends/Tamat
Duration of Studies /
Month/Bulan: Month/Bulan: CGPA
Tempoh Pengajian Year/Tahun: Year/Tahun:
*Please attach a certified copy of your every semester exam result & a testimonial letter from your Institution / Sila sertakan salinan keputusan
peperiksaan setiap semester yang disahkan & surat testimonial pelajar daripada Institut.

STPM

Year of Sitting / Tahun Menduduki

School Name / Nama Sekolah

State/Negeri:

No Subject / Matapelajaran Grade No Subject / Matapelajaran Grade

1 4
2 5
3 6
*Please attach a certified copy of your STPM result / Sila sertakan salinan keputusan STPM anda yang telah disahkan.

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Matriculation or Pre-Diploma / Matrikulasi atau Pra-Diploma

Institution / Institut

Branch / Cawangan

Course / Kursus

Starts/Mula Ends/Tamat
Duration of Studies /
Month/Bulan: Month/Bulan: CGPA
Tempoh Pengajian Year/Tahun: Year/Tahun:
*Please attach a certified copy of your every semester exam result & a testimonial letter from your Institution / Sila sertakan salinan keputusan
peperiksaan setiap semester yang disahkan & surat testimonial pelajar daripada Institut.

D. WORKING EXPERIENCE | PENGALAMAN BERKERJA

Occupation / Pekerjaan Company / Syarikat Duration / Tempoh

Designation/Jawatan: Starts/Mula:

Job Nature/Bidang Kerja: Ends/Tamat:

Designation/Jawatan: Starts/Mula:

Job Nature/Bidang Kerja: Ends/Tamat:

*Please attach your supporting documents for this section, if any / Sila sertakan dokumen sokongan anda untuk bahagian ini, jika ada.

E. PARENTS’ OR GUARDIAN’S INFORMATION | MAKLUMAT IBU BAPA ATAU PENJAGA

Details / Butir-butir Father or Guardian / Bapa atau Penjaga Mother / Ibu

Name / Nama

Relation / Hubungan ‰ Father/Bapa ‰ Guardian/Penjaga

Date Demised (if any) /

Tarikh Meninggal (jika ada)

Occupational Sector /
Sektor Pekerjaan
‰ Government/Kerajaan ‰ Government/Kerajaan
‰ Private/Swasta ‰ Private/Swasta
‰ Self-employed/Bekerja sendiri ‰ Self-employed/Bekerja sendiri
‰ Pensioner/Berpencen ‰ Pensioner/Berpencen
‰ Unempolyed/Tidak bekerja ‰ Housewife/Surirumah

Job / Pekerjaan

Income Per Year / ‰ < 12,000 ‰ < 12,000

‰ 50,001 – 80,000 ‰ 50,001 – 80,000
Pendapatan Setahun ‰ 12,001 – 25,000 ‰ 12,001 – 25,000
‰ > 80,001 ‰ > 80,001
(RM) ‰ 25,001 – 50,000 ‰ 25,001 – 50,000

Dependants / Tanggungan

Home Address /
Alamat Rumah

‰ Same as in Page 1/Sama seperti di Muka 1 ‰ Same as in Page 1/Sama seperti di Muka 1

Home/Rumah: Home/Rumah:

Telephone / Telefon Mobile/Bimbit: Mobile/Bimbit:

Office/Pejabat: Office/Pejabat:

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F. SPONSORSHIP FROM INDUSTRIES | PENAJAAN DARIPADA INDUSTRI

Please attach an undertaking letter of sponsorship from the sponsoring company/body, if any.

Sila sertakan bersama surat pengesahan tajaan daripada syarikat/badan yang membuat penajaan, jika ada.

G. INTERVIEW OR ENTRANCE TEST | TEMUDUGA ATAU UJIAN KEMASUKAN

Only eligible candidates will be called up for the Interview/Entrance Test session. Candidate will be contacted according to
the Postal Address given in the Personal Details column (Page 1).

Hanya pemohon yang layak sahaja yang akan dipanggil untuk sesi Temuduga/Ujian Kemasukan. Calon akan dihubungi
melalui Alamat Surat-menyurat yang diberikan dalam ruangan Butiran Peribadi (Muka 1).

H. PROCESSING FEE | YURAN PEMPROSESAN

Enclosed herewith is RM 10.00 Money Order (MO)/Postal Order (PO) – non-refundable, as processing fee. Cash is also
accepted upon by-hand submission of Application Form to GMI (applications without processing fee will not be processed).

Bersama-sama ini disertakan MO/PO sebanyak RM 10.00 - tidak dikembalikan, sebagai yuran pemprosesan. Tunai juga
diterima jika Borang Permohonan dihantar sendiri ke GMI (permohonan tanpa yuran pemprosesan tidak akan diproses).

I. APPLICATION CHECKLIST | SENARAI SEMAK PERMOHONAN

Please check & enclose these documents upon returning this form. All copies submitted must be certified / Sila periksa & sertakan salinan
dokumen-dokumen di bawah semasa memulangkan borang ini. Semua salinan yang dihantar hendaklah disahkan.

COMPULSORY / WAJIB IF RELEVANT / JIKA BERKAITAN

‰ Completed form / Borang yang lengkap
‰ Applicant’s IC & Birth Certificate copy / Salinan Kad
Pengenalan & Sijil Lahir pemohon
‰ Applicant’s SPM/SPMV result certificate or slip copy /
Salinan sijil atau slip keputusan SPM/SPMV pemohon
‰ Processing fee / Yuran pemprosesan
‰ Student’s testimonial letter from Institute / Surat
testimonial pelajar daripada Institut
‰ Copy of every semester exam result slip at Institution /
Salinan slip keputusan peperiksaan setiap semester di
Institut
‰ Other supporting documents / Lain-lain dokumen
sokongan

J. ACKNOWLEDGEMENT | PENGAKUAN

I confirm that the above particulars are true and all copies of certificates attached are documents to support my application
for entrance to GMI. I am aware that should the particulars given and copies of certificates be false, GMI has the right to
reject my application.

Saya mengaku bahawa semua maklumat di atas dan salinan sijil yang disertakan adalah benar bagi menyokong
permohonan saya untuk memasuki GMI. Saya sedar sekiranya maklumat dan salinan sijil yang disertakan adalah palsu,
maka GMI mempunyai hak untuk menolak permohonan saya.

Applicant’s Signature / Date /

Tandatangan Pemohon Tarikh
REV.01/2008

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