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Surau Al-Hikmah, Jalan SS 18/4, 47500 Subang Jaya, Selangor Darul Ehsan

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No. Pendaftaran JAIS: SPS/PRP/08/7(SEM)-303

Tel: 03- 5636 1095
019- 281 6307

APPLICATION FORM

APPLICANT DETAILS

Name : ____________________________________________________

Passport/I.C. No. : ____________________________________________________

Date of birth : ____________________________________________________

Fathers name : ____________________________________________________

Mothers name : ____________________________________________________

Contact person & no: ____________________________________________________

Postal address : ____________________________________________________

____________________________________________________

EDUCATIONAL RECORD
School attended (or furthest secular education) ________________________________

Level achieved _______________________________________ in the year _________


Madrasah attended (or furthest Islamic education) ______________________________

Level achieved _______________________________________ in the year _________


HEALTH
Does the applicant suffer from any illness that would affect his studies or his stay at the
institute? If yes, specify.

________________________________________________________________________

________________________________________________________________________

A guardian is person responsible for the student for the period of time outside madrasah. A
guardian of a female student should be a muhrim.

Guardians name : __________________________ Relationship: _______________

Guardians contact : ____________________________________________________

Registration Fee
Registration fee is RM400. The payment is made on the acceptance of student to study in
the madrasah. The place of study shall not be reserved for student who has yet to pay this
fee.

Annual Fee
The annual fee is RM4800. Payment can be staggered into monthly payments. Payments
shall be acknowledged in periodical statements. The final settlement shall be not later than
October.

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Fees Card
All students shall be issued a FEES Card. In each occasion, please make sure that the
recipient of the fees is a member of the staff and signs the card to acknowledge the
respective payment. All payments should be made to:

Name : MAH SJ Resources
Bank : Bank Muamalat SS15/5A Subang Jaya
No. : 1206-0002579-71-4

ACCEPTANCE
1. Submission of this form shall be considered as a formal application to study in the
institution.
2. The decision of acceptance shall be made after a muzakarah session between the
parents/guardians and mudir. The prospective student may be present.
3. The madrasah shall inform the applicant the status of the application as soon as
possible, inshaAllah.
4. Application shall not be processed if the agreement below has not been signed.
Kindly read carefully and sign only if you have agreed on all the terms mentioned.

The Agreement and Declaration of Parents

o I, the undersigned, testify that all that are submitted above as true.
o I am applying on behalf of the above mentioned student to enroll at this institution.
o I understand the Rules and Regulation of the Madrasah and agree to abide by it.
o I, in my capacity as the PARENT/GUARDIAN/SPONSOR of the student mentioned
above, hereby undertake to pay the fees as indicated above
o I am responsible for the arrangement of the students visa.
o I hereby agree that:
1. The parents shall not intervene in the operation of the madrasah. Any feedback must
be addressed to the mudir in writing.
2. The madrasah will do its utmost to take care of the students safety, but is NOT
responsible for any mental or physical harm that may befall the student for all time
during the stay in the madrasah or away from the madrasah.
3. Punctuality is of high importance. Disciplinary action shall be taken on students
returning late to the madrasah.
4. Any item(s) found in possession of the student, which have been ruled impermissible
by the madrasah, will be confiscated. It is entirely up to the madrasah to do what is
deemed necessary with the confiscated item(s). The parents have no more rights
over the item(s).
5. The madrasah will inform the student and may update the parents of the items which
have been declared impermissible by the madrasah.
6. The madrasah has the right to expel the student who is found to be unfit,
academically or behaviourally, to continue his/her study in the madrasah.

We put our trust in Allah swt.


Signature of parent/guardian/sponsor : _______________________________________

Name of parent/guardian/ sponsor : _______________________________________

This application was completed and submitted on (date) ____________________