UniMAP2018 Page 1

Reg.No.

1. Personal Information * Please fill in the form in BLOCK LETTERS.

Full Name (Exactly the same as your passport) (in English)

Given name (English) Family Name (English)

(Day) (Month) (Year)

Religion

Mother Tongue

Number Type of Passport

　　

Date of Issue Date of Expiry(Day) (Month) (Year) (Day) (Month) (Year)

Relationship

Relationship

Entry Form for International Environmental and Ecological Camp 2018 (IEEC2018)

Age (as of the starting day of the

programme)

Middle Name (English) (if any)

Name

Nationality Sex

Full Name (in Mother language)

Date of Birth(as shown on your

passport)

………………………………………... 　 ………………………………………………..

Marital Status

Passport**

Current Address

Address

Tel: Fax:

Mobile: E-mail:

Contact Person in Emergency

*It shall be your parent.*If you live with him/her,

please leave address blank.

Full Name

Address

Tel: Fax:

Mobile: E-mail:

Profession/Occupation:

*If you do not have phone at your current address,

please write contact person and number.

Full Name

Phone Number: E-mail:

**Passport: If you have a valid passport, please fill in the passport section. If you don't have a passport, please leave the section blank.

Photo (taken within 3

months) Please write your name on the back

of your photo.

Male Female

Buddhist Christian Roman Protestant Other

Hindu Muslim Others

Single Married

Private Diplomat Official

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2. Health ConditionBlood Type

Good

Not taking any medicines

Taking medicines regularlly (Specified： 　　　　　　　　 　　　　　 )　　　

Pregnancy*for women

Yes 　 No

None

Others ( )

None

Pork Beef Chicken Mutton/Lamb　 Shrimp　 Crab Shellfish

Fish Egg Others ( )

None

None

Dogs Cats House dust Others ( 　　　　　　　　 　　　　 )

3. Academic DetailsLocation (city,province)

LanguageSpeaking : Good Fair Poor Speaking : Good Fair Poor

Writing : Good Fair Poor Writing : Good Fair Poor

Reading : Good Fair Poor Reading : Good Fair Poor

*Please attach your student ID along with the application form

Tel:

Health Condition

Having Chronic disease　 Please specify: chronic lung disease (asthma, chronic obstructive lung disease etc.) immunodeficiency state (T cell immunodeficiency etc.)　

chronic heart disease (congenital heart disease, coronary artery disease etc.) metabolic disease (diabetes) □renal dysfunction □obesity □myasthenia gravis infectious diseases (Specified: ) others ( )

1. A permission letter by doctor is required in the pre-departure orientation. 2. Medical treatment cost related to the chronic disease is not covered by the programme insurance.

Medicine

*Pregnant women cannot participate in IEEC2018 owing to maternal and child health reason.

Food Allergies(which may cause allergic reaction)

Shrimp Crab Shellfish Fish Egg

Yes No

Food Restriction (for religion or custom reason)

*Please be noted that the meals provided in the programme cannot meet all the requests from the participants.

Dietary Requirements Vegetarian Vegan Halal Others ( )

Other Allergies and Restriction

Information of your School/University

Name of School / University

Level of English Level of Malay Language

Other Language

Fax:

Field of study

Grade/school year as of the day of the flight to Malaysia

* I confirm that I am a student (possess student ID)

For Supervisor onlyProfession/Occupation:

Title

A B O AB UNKNOWN

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4. Essay *Please answer the two questions in 150 words. You may attach additional pages as needed.

5. Other Information

Yes No If Yes, When?

6. Payment Details

RM

Account Details

Payment notes: • The invoice will be issued according to the rate stated above.

• Registration fee must be paid by 7 May 2018• Please email us a copy of your payment receipt as a proof of payment to ieec@unimap.edu.my•Originalreceiptswillbegivenontheregistrationday.

Name of Recipient

Name of Local Bank

Bank address

09010001234710

BMMBMYKL

Other information/ reference

Universiti Malaysia Perlis

Cheque

Credit cards

Muamalat Malaysia Berhad

11, Jalan Bukit Lagi, 01000 Kangar,Perlis, MALAYSIA

Payment for IEEC2018

Have you ever been to Malaysia before?

In currency

If Yes, what was the purpose of the visit and where did you visit?

USD

6 8 10 12 14

Dr./ Mr./ Ms.

Local Order /Purchase Order

T-shirt size (UK size)

Electronic Fund Transfer (EFT) / Telegraphic Transfer (TT)

Payment method

Account No

Swift Code

Has paid the amount of

1. Why do you want to participate in the IEEC2018 ?

2. What will you be able to contribute to it?

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Agreement of the Application Guidelines for IEEC2018I have read and understood the terms and conditions in the "Application guidelines for IEEC2018."

(Day) (Month) (Year)

DeclarationI hereby certify that the statements made by me in this form are true and correct to the best of my knowledge.

Signature: Date: / /