REGISTRATION FORM FOR MALAYSIAN STUDENTS IN MIDWEST REGION, USA
Welcome to Education Malaysia Chicago's registration front desk. Please kindly fill up this form and submit it to us. All information will be kept in private and confidential.
Email address *
Name (According to MyKad / Passport) *
Cell Phone Number *
Personal Email *
MyKad Number *
Passport Number
State Origin in Malaysia *
Permanent Address in Malaysia
State in the Midwest Region, US *
Present Address in USA *
Name of University *
Course / Major Name *
Level of Study *
Required
Study Duration - Start *
MM
/
DD
/
YYYY
Study Duration - End *
MM
/
DD
/
YYYY
Expected Date of Completion
MM
/
DD
/
YYYY
Sponsors / Scholarship *
Name & Email of Academic Advisor
Address of University *
Marital Status *
Required
Facebook Account
Insurance Card Number *
Current Visa Status *
Emergency Contact in Malaysia (Name, Address & Phone No) *
Emergency Contact in USA (Name, Address & Phone No)
Spouse Name, Email & Phone (if any)
Please kindly upload profile picture for EM Student Card purposes *
Required
Thank you for your cooperation. Education Malaysia Chicago will process your Student Card and it will be emailed to you soon.
Submit
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