Final Application Registration 20160629 Final Final Application_Registration_20160629 Final Created page 1
Final Application Registration 20160629 Final Final Application_Registration_20160629 Final Created page 2

Final Application Registration 20160629 Final Final Application_Registration_20160629 Final Created

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  • eQµaHCaPasaExµr eKatþnam nam

    Ex (MMM) éf¶ (DD) qñaM (YYYY)

    B½t’manpÞal;xøÜn (Personal Information)

    Name in Khmer eQµaHCaGkSrLataMg Name in Latin

    Family Name Given Name ePT Sex

    Rbus Male

    RsI Female

    eQµaHCaPasaExµr eKatþnam nam

    Name in Khmer eQµaHCaGkSrLataMg Name in Latin

    Family Name Given Name

    éf¶ Ex qñaMkMeNIt Date of Birth

    elxTUrsBÞ Telephone

    Gasydæanbc©úb,nñ pÞHelx Current Address No.

    pøÚvelx Street

    XuM¼sgáat; Commune/Sangkat

    Rsuk¼xNÐ District/Khan

    extþ¼Rkug Province/City

    muxrbr Occupation

    m®nþIraCkar Government Official

    buKÁlikÉkCn Employee

    sisS b¤nisSit Student

    GaCIvkr Businessperson

    buKÁlikGgÁkar NGO Staff

    BinÞú Score

    kRmit Level

    epSg² Miscellaneous

    eQµaH«Buk

    B½t’manmatabita b¤GñkGaNaBüa)al (Parents/Guardian Information)

    Father’s Name elxTUrsBÞ Telephone

    eQµaHmþay Mother’s Name

    muxrbr Occupation

    muxrbr Occupation

    elxTUrsBÞ Telephone

    eQµaHGñkGaNaBüa)al Guardian’s Name

    GñksmÖasn_ Interviewer

    htßelxa Signature

    Gayu Age

    smþal; Remark

    muxrbr Occupation

    elxTUrsBÞ Telephone

    Gasydæanbc©úb,nñ Current Address

    pÞHelx No.

    dUcxagelI Same as above

    pøÚvelx Street

    XuM¼sgáat; Commune/Sangkat

    Rsuk¼xNÐ District/Khan

    extþ¼Rkug Province/City

    1. fñak;PasaGg;eKøssRmab;kumar (Kid Program)

    B½t’manGMBIkmµviFIsikSa (Program Information)

    Pre-kid Program

    sUmeRCIserIskmµviFIEdlGñkcg;sikSa (Please check the program you wish to attend.)

    Kid Program

    1. fñak;PasaGg;eKøssRmab;kumar (Kid Program) Pre-kid Program Kid Program

    2. fñak;PasaGg;eKøssRmab;mnusSeBjv½y (Adult Program) General English Program (GEP) Advanced English Program (AEP) English for Specific Purposes (ESP)

    Test Result kalbriecäT Date

    Ex (MMM) éf¶ (DD) qñaM (YYYY) lT§pletsþ

    A Mengly J. Quach Education.

    sßanPaBRKYsar Marital Status

    enAlIv Single

    manRKYsar Married

    sBa¢ati Nationality

    TMB½r1 én2

    fñak;1éf¶ suRk 1-day Class Fri

    fñak;cugs)aþh_ esAr_ Weekend Class Sat

    éf¶sikSa Study Day

    fñak;5éf¶ cnÞ dl; suRk 5-day Class Mon-Fri

    fñak;2éf¶ 2-day Class

    cnÞ BuF Mon, Wed

    GgÁar RBhs,t× Tue, Thu

    em:agsikSa Study Time

    em:agsikSa Study Time

    éf¶sikSa Study Day

    cnÞ dl; suRk Mon-Fri

    smþal; Remark

    2. fñak;PasaGg;eKøssRmab;mnusSeBjv½y (Adult Program) General English Program (GEP) Advanced English Program (AEP) English for Specific Purposes (ESP) TOEFL Preparation Course

    3.fñak;bNþúHbNþalCMnajkMuBüÚT½r (Computer Training Course) CMnaj Skill

    éf¶cab;epIþm Start Date

    3.fñak;bNþúHbNþalCMnajkMuBüÚT½r (Computer Training Course)

    kUdetsþ GtþelxsisS Test Code Student ID No.

    saxa em:AesTug MTT

    TYleKak TKCampus

    cak;GERg CA

    kUdetsþ GtþelxsisS Test Code Student ID No.

    sareGLicRtÚnic E-mail

    TOEFL Preparation Course

    saxa em:AesTug MTT

    TYleKak TKCampus

    cak;GERg CA

    CMnaj Skill

    éf¶cab;epIþm Start Date

  • )aT ¼ cas+ Yes

    eT No

    )aT ¼ cas+ Yes

    eT No

    In case the student is sick or has any accident, would you allow the doctor from the Mengly J. Quach Student Health Center to check up / treat him or her?

    B½t’manGMBIsuxPaB (Health Information) krNIsisSmanGakarminRsYlxøÜn b¤man]bTÞvehtuNamYy)anekIteLIg etIelakGñkGnuBaØat[evC¢bNÐiténmCÄmNÐlsuxPaBsisS em:glI eC> KYc Binitü nig[júaMfñaMEdr b¤eT?

    TMnak;TMngeBlcaM)ac; nigGvtþman (Absence and Emergency Contact)

    In case of absence or emergency, please contact eBlGvtþman b¤krNIcaM)ac;sUmTak;TgeQµaH

    If student (16 years old or over) is absent without permission, would you like the school to contact you? etIelakGñkcg;[viTüasßan eFVIkarTak;TgEdr b¤eT enAral;eBlsisSEdlmanGayucab;BI16qñaMGvtþman\tc,ab;?

    Relationship RtUvCa

    Telephone elxTUrsBÞ

    ´Camatabita b¤GñkGaNaBüa)alsisSxagelIBitCa)anGan nigÉkPaBnUvbTbBaØtþisala ehIysUmGHGagfaB½t’manEdl)anpþl;CUnxagelIBitCaRtwmRtUv.

    Relationship RtUvCa

    Telephone elxTUrsBÞ

    Parent/Guardian participating in the oral interview

    I, the parent/guardian of the above student, have read and agreed to the school rules and regulations, and I hereby declare that the information given in this form is true and correct to the best of my knowledge.

    htßelxamatabita b¤GñkGaNaBüa)al ¼ Parent/Guardian Signature kalbriecäT ¼ Date

    Ex (MMM) éf¶ (DD) qñaM (YYYY)

    ´)aT¼nag´ eRCIserIsmksikSaenAviTüasßan GnþrTVIb GaemrikaMg tamry³ b¤edaymUlehtu I choose to study at the American Intercon Institute because

    TMB½r2 én2

    Does the student have any known allergies to medications? etIsisSmanRbtikmµnwgfñaMGVIEdr b¤eT?

    If yes, please describe RbsinebIman sUmerobrab;

    A Mengly J. Quach Education.

    eQµaHmatabita b¤GñkGaNaBüa)alEdlcUlrYmsmÖas

    GñksmÖasn_ Interviewer

    htßelxa Signature

    BinÞú Score

    kRmit Level

    smþal; Remark

    )aT ¼ cas+ Yes

    eT No

    TMnak;TMngB½t’man

    Mao Tse Tong Campus (Main Office):

    #140 & 210, Mao Tse Tong Blvd.,

    Phnom Penh, Kingdom of Cambodia

    Tel: (855) 23 223 295, (855) 23 221 222,

    (855) 11 388 868, (855) 93 217 217

    Fax: (855) 23 999 930

    Toul Kork Campus:

    #26, St. 289, Sangkat Boeung Kak I,

    Khan Toul Kork, Phnom Penh,

    Kingdom of Cambodia

    Tel: (855) 23 959 555, (855) 77 217 700

    Fax: (855) 23 993 496

    Chak Angre Campus:

    #824, National Road 2, Sangkat

    Chak Angre Krom, Khan Mean Chey,

    Phnom Penh, Kingdom of Cambodia

    Tel: (855) 23 960 999, (855) 23 960 333,

    (855) 92 666 706

    Fax: (855) 23 978 899

    aii.mjqeducation

    MJQ Educationinfo@aii.edu.kh, info@mjqeducation.edu.kh

    www.aii.edu.kh, www.mjqeducation.edu.kh

    Contact Information

    sRmab;kareRbIR)as;épÞkñúg (For official use only)