APPLICATION FORM

STEP 1 STEP 1

Are You Malaysian? Are You Malaysian? Yes No

STEP 2 STEP 2

Centre* Centre*Bukit MertajamCherasIpohIpoh GardenKepongKlangKluangKLCCMelakaMuarPJ SS2PuchongPuchong UtamaSerdangSelayangSri PetalingTaipingTeluk Intan

STEP 3: PROVIDE YOUR DETAILS STEP 3: PROVIDE YOUR DETAILS

Title Title Mr Mrs Ms

Given Name*

Surname*

Date of Birth Date of Birth

Date* Date*12345678910111213141516171819202122232425262728293031

Month* Month*JANUARYFEBRUARYMARCHAPRILMAYJUNEJULYAUGUSTSEPTEMBEROCTOBERNOVEMBERDECEMBER

Year* Year*20172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Gender Gender Male Female

Nationality* Nationality*AfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanThe BahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBotswanaBrazilBruneiBulgariaBurundiCabo VerdeCambodiaCameroonCanadaCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonThe GambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMaldivesMaliMaltaMauritaniaMauritiusMexicoMongoliaMoroccoMyanmar (Burma)NamibiaNauruNepalNetherlandsNew ZealandNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaudi ArabiaSenegalSerbiaSingaporeSlovakiaSloveniaSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTunisiaTurkeyTurkmenistanUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Contact Details Contact Details

Phone

Mobile*

Email*

Emergency Contact Emergency Contact

In case of emergency, please contact: In case of emergency, please contact:

Emergency Contact Name*

Relationship

Phone*

STEP 4: COURSE APPLIED FOR STEP 4: COURSE APPLIED FOR

Please select to submit the form*: Please select to submit the form*: Erican International English Cambridge English Plus Business English IELTS Preparation Course Young Learners English Plus Mandarin Course Japanese Course

STEP 5: ADDITIONAL INFORMATION STEP 5: ADDITIONAL INFORMATION

Would you like Erican to help you find accommodation? Would you like Erican to help you find accommodation? Yes No

How did you find out about Erican Language Centre? How did you find out about Erican Language Centre?AgentsEvent/FairFriends/ColleaguesInternetNewspaperSchool/Counsellor

Please select to submit the form: Please select to submit the form: I certify that the information contained herein is accurate and correct to the best of my knowledge. I have read and hereby accept all Erican Language Centres’ terms and conditions listed in this online application. I have read and understood and hereby consent to the collection and processing of my Personal Data and Sensitive Personal Data as defined under the Personal Data Protection Act 2010 (“PDPA”) I have read, understood and agree to be bound by the Terms and Conditions including the Cancellation and Refund Policy. I agree to pay all fees owing and by the due date.