COLLECTION OF CREDENTIAL ON BEHALF *

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RF07
Version : 01
ACADEMIC MANAGEMENT AND ADMISSION DIVISION’S COPY Revision : 01
Effective Date : 01/04/2017

Our References : IIUM/203/4/13 Date :

Instruction:
Please complete Section A, B and C and attached with this form a photocopy of yours and the
representative identity card/ passport/ matric card.

Director
Academic Management and Admission Division, IIUM

Dear Sir,

SECTION A: TYPES OF DOCUMENTS TO COLLECT ON BEHALF

(TO BE FILLED BY THE STUDENT)

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SECTION B: STUDENT’S INFORMATION

Name : __________________________________________
Matric / ID / Passport No. : ___________________________________________
Programme : _______________________________________________

SECTION C: REPRESENTATIVE INFORMATION

Name : ___________________________________________
Matric / ID / Passport No. : ___________________________________________
Programme (if applicable) : ___________________________________________

I confirmed that my representative shall have the authority to sign acknowledgement of the
receipt of the said document. I hereby undertake that I shall not hold IIUM responsible if the
said document is lost or undelivered after collected by my representative.

Thank you.

Yours faithfully

___________________________
(Signature)
Office address International
Academic Management and Admission Division, IIUM
Gombak, Selangor Darul Ehsan, Malaysia Islamic
Tel: 03 6421 6421 Fax : 03 6421 4724 / 4160 University
Email : amad@iium.edu.my
www.iium.edu.my/division/amad Malaysia