Online Application

19-1 & 19-2, Plaza Danau 2, Jalan 5/109F,
Taman Danau Desa Off Jln. Klang Lama,
58100 Kuala Lumpur, Malaysia.
Telephone: +603.7981.1821
Fax: +603.7987.8787
Email: admin@mediced.com.my

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Online Application

To apply, please download the form (pdf document), fill it up, and fax it to any of the above numbers. You can also fill up the form below and send it back to us online.

*Full Name:

Date:

Identity Card Number:

Passport Number:

Correspondence Address:

Postcode:

Town:

Telephone Number (House):

*Telephone Number (Mobile):

*E-mail Address:

Recent Secondary School/College:

Highest Level Education:	SPM
	STPM
	MATRICULATION
	O-LEVELS
	A-LEVELS
	Others:

Course Interested:	Predatory (Pre-Medic)
	Dentistry
	General Medicine
	Pharmacy

Preferred Universities:	1.
	2.
	3.

Down Payment
Payment Method: