SAM21 Application Form A. Applicant/Participant Personal Details Full Name (same as passport) * Gender * Male Female Country * Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Côte d‘Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe Mobile Phone Number * International format Email * B. Education Background Home Institution/University Please state your university Home Faculty * Programme Name * Chemical Engineering, English, Business, Chemistry, Psychology etc. C. Study Abroad Programmes English Speaking Proficiency * Very Good Good Poor Very poor English Reading Proficiency * Very Good Good Poor Very poor English Writing Proficiency * Very Good Good Poor Very poor G. Attachment and Declaration Personal Statement - Why do you want to join this program. (Important for scholarship selection) * Drop a file here or click to upload Choose File Maximum upload size: 5.12MB Please prepare a few paragraph of your personal statement, a short description of yourself and your motivation of joining this program. Please also include your expectation of the program. Please Upload your CV * Drop a file here or click to upload Choose File Maximum upload size: 5.12MB Please prepare a few paragraph of your personal statement, a short description of yourself and your motivation of joining this program. Please also include your expectation of the program. Checkboxes * I hereby declare that the information provided in this form is true. I acknowledge that Universiti Teknologi Malaysia reserves the right to vary or reserve any decision regarding admission or enrolment made on the basis of the given information.