SENARAI SEMAK PERMOHONAN

BIDANG PERUBATAN/PERGIGIAN/PENGAJIAN ISLAM KE UNIVERSITI DI JORDAN

(untuk kegunaan pemohon)

Sila lengkapkan borang yang berkaitan dan pastikan semua dokumen yang telah disahkan mencukupi. Perhatian:

i. Borang yang tidak lengkap tidak akan diproses ii. Tandakan (√) jika maklumat/dokumen lengkap dan mencukupi

1) Dua (3) salinan slip permohonan yang telah dicetak dalam talian. 2) Dua (2) terjemahan Slip Sijil Pelajaran Malaysia (SPM) dalam Bahasa Arab yang telah

disahkan di Bahagian Konsular, Kementerian Luar Negeri. 3) Dua (2) salinan muka hadapan dan belakang terjemahan Sijil Pelajaran Malaysia

(SPM) dalam Bahasa Arab yang telah disahkan. 4) Tiga (3) Salinan Slip Sijil Pelajaran Malaysia (SPM) yang telah disahkan. 5) Dua (2) terjemahan Sijil Lahir / Surat Beranak / Borang W dalam Bahasa Arab yang

telah disahkan di Bahagian Konsular, Kementerian Luar Negeri.

6) Dua (2) salinan terjemahan muka hadapan dan belakang Sijil Lahir / Surat Beranak / Borang W dalam Bahasa Arab yang telah disahkan.

7) Dua (2) salinan Sijil Lahir / Surat Beranak / Borang W yang telah disahkan.

8) Lima (5) salinan pasport Malaysia dengan tempoh sah sekurang-kurangnya dua (2) tahun yang telah disahkan.

9) Dua (2) salinan Kad Pengenalan yang telah disahkan.

10) Dua (2) salinan Pengakuan Tanggungan Kos Rawatan Dan Kesihatan yang telah disahkan.

11) Dua (2) salinan laporan perubatan yang telah disahkan (Gunakan borang Medical Certification Form yang disertakan). Nota: Pemeriksaan perubatan boleh dijalankan oleh Hospital/Klinik kerajaan atau swasta.

12) Enam (6) keping gambar berukuran pasport dan ditulis nama pemohon & no. kad pengenalan di belakangnya.

Tandakan (√)

13) Bank Draf atas nama ‘Akauntan NEGARA MALAYSIA-KPT-T’ sebanyak RM520.00 untuk semua Universiti di Jordan Peringatan: i) Bank draf mesti dalam matawang Ringgit Malaysia. ii) Nama dan no. kad pengenalan hendaklah ditulis dengan pensil di belakang bank draf.

14) Satu (1) salinan aku janji permohonan melanjutkan pengajian ke Timur Tengah bagi sesi 2018/2019

PENGAKUAN TANGGUNGAN KOS RAWATAN DAN KESIHATAN

Pengarah Education Malaysia Jordan No. 24 Moh’d Baseem Al-Khammash Street Sweifieh P.O. Bax 143310 Amman 11185 JORDAN Tuan, PENGAKUAN TANGGUNGAN KOS RAWATAN DAN KESIHATAN Adalah dengan ini saya ......................................................ibubapa/penjaga

(Nama Ibu bapa/Penjaga) kepada........................................................bertanggungjawab ke atas kesihatan

(Nama Pemohon) anakjagaan saya semasa tempoh pengajian beliau di Jordan. Sekiranya beliau perlu mendapat rawatan di mana-mana institusi rawatan di Jordan, saya akan menanggung segala kos rawatan tersebut.

Sekian, terima kasih.

................................................ (Tandatangan ibubapa/penjaga) Nama ibu bapa/penjaga : ................................................

No. Kad Pengenalan : ................................................

Tarikh : ................................................

Saya mengaku bahawa segala maklumat yang diberikan adalah benar. Tandatangan Pemohon : ___________________________ Nama Pemohon : ___________________________ Tarikh : ___________________________

MEDICAL CERTIFICATION FORM

MEDICAL CERTIFICATION FORM

The student must complete this form and hand it to the Medical Officer at the time of examination. NAME OF STUDENT :……………………………………………………………………....... (IN CAPITAL LETTERS) NAME OF PARENT/: ………………………………………………………………………... GUARDIAN ADDRESS: …………………………………………………………………….......

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

DATE OF BIRTH :……………………. PLACE OF BIRTH : …………………………

OLD I.C. NO. :……………………. NEW I.C. NO. : …………………….......

MARITAL STATUS :………………........

Have you ever suffered from :- a. Spitting of blood, asthma, pleurisy, or from any ……………………………..

complaint of the lungs?

b. Rheumatism, gout, fainting fits, or rupture?…………………………….. c. Nervous complaint, mental disorder or fits?…………………………….. d. Any other disease or from serious personal injury?…………………………….. e. Have you been hospitalized before? For what illness?…………………………….. f. Are you suffering from frequent headache?…………………………….. g. Are you allergic to any drug or food?……………………………..

If yes, please specify Have any members of your family or immediate relatives ……………………….. been, or are now suffering from tuberculosis, insanity or fits?

I hereby declare that the information given is true and complete. Date: ………………………………. Signature:………………………… Note: Please bring along your eye glasses for inspection by the medical officers

(if applicable). 1

MEDICAL CERTIFICATION FORM SECTION II : (To be filled by the Medical Officer who examines the student)

MEDICAL EXAMINATION FOR ADMISSION TO UNIVERSITY IN JORDAN

Medical Officers are requested to make a thorough examination of the student and complete the report below. 1. a. Is the applicant known to you ?

a)………………………….. b. Have you attended to him/her before? b)………………………….. c. Height c)………………………….. d. Weight d)…………………………..

2. EXAMINATION OF EYES :-

a. Vision (uncorrected) a………………………….. b. Vision (corrected with glasses) b…………………………..

c. Colour Blind c…………………………..

3. EXAMINATION OF EARS :-

a. Any discharge present a………………………….. b. Condition of drum b…………………………..

c. Acuity of hearing c…………………………..

4. EXAMINATION OF TEETH 5. EXAMINATION OF THROAT

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MEDICAL CERTIFICATION FORM

6. EXAMINATION OF CHEST :-

a. Any abnormally of form a………………………….. b. Expansion normal? b…………………………..

c. Equal on both sides? c…………………………..

d. Percussion d…………………………..

e. Ausculation e…………………………..

f. X-ray examination report f…………………………...

7. CONDITIONS OF HEART :-

a. Rhythm a………………………….. b. Character of impulse at Apex beat b…………………………..

c. Position of Apex beat c…………………………..

d. Any alteration of size d…………………………..

e. Any murmurs present e…………………………..

f. Exercise tolerance test f…………………………...

8. PULSE :-

a. Rate a………………………….. b. Character b…………………………..

c. Any evidence of arterial changes c…………………………..

9. BLOOD PRESSURE

a. Mercurial manometer preferred a………………………….. b. Taking reading lying or sitting b…………………………..

10. IS THERE ANY ENLARGEMENT OF :-

a. The liver, or a…………………………..

b. Spleen, or b…………………………..

c. Any abnormal swelling in the abdomen? c………………………….. 3

MEDICAL CERTIFICATION FORM

11. EXAMINATION OF URINE :-

a. S. Gravity a………………………….. b. Albumin b…………………………..

c. Sugar c…………………………..

d. Acetone d…………………………..

e. Microscopical examination of deposit e…………………………..

12. EXAMINATION OF HERNICAL a…………………………..

ORIFICERS

13. EXAMINATION OF NERVOUS SYSTEM :-

a. Condition of patellar reflexes? a………………………….. b. Condition of ankle reflexes? b…………………………..

c. Condition of plantar reflexes? c…………………………..

d. Are the pupils equal ? d…………………………..

e. Do the pupils react to light? e…………………………..

f. Do the pupils react to accommodations? f…………………………...

g. Any sensors loss? g…………………………..

Any further re-examination which the examining officer considers necessary as a result thereof …………………………………………………….. I hereby certify that I have examined ………………………………………………… and I find that he/she is free from organic disease and is fit for admission to university in Jordan.

Signature………………………………... Qualifications…………………………… Hospital/Clinic………………………….. ………………………………………….. ………………………………………….. Date ……………………………………..

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