Application Form Are You Malaysian? Are You Malaysian? Yes No Which centre is most convenient for you? Which centre is most convenient for you? Centre* Centre*KLCCCherasPuchong UtamaPuchongMelakaTeluk IntanBukit MertajamIpohIpoh Garden Provide your details. 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*20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 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* Course applied for 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 Additional Information 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. Submit