Final Application Registration 20160629 Final · Final Application_Registration_20160629 Final...
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eQμ aHCaPasaExμ r eKatþ nam nam Ex (MMM) éf¶ (DD) qñ a M (YYYY) B½t’manpÞal;xøÜn (Personal Information) Name in Khmer eQμ aHCaGkSrLata M g Name in Latin Family Name Given Name ePT Sex Rbus Male RsI Female eQμ aHCaPasaExμ r eKatþ nam nam Name in Khmer eQμ aHCaGkSrLata M g Name in Latin Family Name Given Name éf¶ Ex qñ a M kM eNI t Date of Birth elxTU rsBÞ Telephone Gasydæ anbc© ú b,nñ pÞ Helx Current Address No. pø Ú velx Street XuM¼sgáat; Commune/Sangkat Rsuk¼xNÐ District/Khan extþ¼Rkug Province/City mu xrbr Occupation m®nþ I raCkar Government Official bu KÁ li kÉkCn Employee si sS b¤ ni sS i t Student GaCI vkr Businessperson bu KÁ li kGgÁ kar NGO Staff Bi nÞ ú Score kRmi t Level epSg² Miscellaneous eQμ aH«Bu k B½t’manmatabita b¤GñkGaNaBüa)al (Parents/Guardian Information) Father’s Name elxTU rsBÞ Telephone eQμ aHmþ ay Mother’s Name mu xrbr Occupation mu xrbr Occupation elxTU rsBÞ Telephone eQμ aHGñ kGaNaBüa)al Guardian’s Name Gñ ksmÖ asn_ Interviewer htß elxa Signature Gayu Age smþ al; Remark mu xrbr Occupation elxTU rsBÞ Telephone Gasydæ anbc© ú b,nñ Current Address pÞ Helx No. dU cxagelI Same as above pø Ú velx Street XuM¼sgáat; Commune/Sangkat Rsuk¼xNÐ District/Khan extþ¼Rkug Province/City 1. fñ ak; PasaGg; eKø ssRmab; ku mar (Kid Program) B½t’manGMBIkmμviFIsikSa (Program Information) Pre-kid Program sU meRCI ser I skmμ v i FI EdlGñ kcg; si kSa (Please check the program you wish to attend.) Kid Program 1. fñ ak; PasaGg; eKø ssRmab; ku mar (Kid Program) Pre-kid Program Kid Program 2. fñ ak; PasaGg; eKø ssRmab; mnu sSeBjv ½ y (Adult Program) General English Program (GEP) Advanced English Program (AEP) English for Specific Purposes (ESP) Test Result kalbr i ecä T Date Ex (MMM) éf¶ (DD) qñ a M (YYYY) lT§pletsþ A Mengly J. Quach Education. sß anPaBRKY sar Marital Status enAlI v Single manRKY sar Married sBa ¢ ati Nationality TM B½ r1 én2 fñ ak; 1éf¶ su Rk 1-day Class Fri fñ ak; cu gs)a þ h_ esAr _ Weekend Class Sat éf¶ si kSa Study Day fñ ak; 5éf¶ cnÞ dl; su Rk 5-day Class Mon-Fri fñ ak; 2éf¶ 2-day Class cnÞ Bu F Mon, Wed GgÁ ar RBhs,t× Tue, Thu em: agsi kSa Study Time em: agsi kSa Study Time éf¶ si kSa Study Day cnÞ dl; su Rk Mon-Fri smþ al; Remark 2. fñ ak; PasaGg; eKø ssRmab; mnu sSeBjv ½ y (Adult Program) General English Program (GEP) Advanced English Program (AEP) English for Specific Purposes (ESP) TOEFL Preparation Course 3.fñ ak; bNþ ú HbNþ alCM najkM u Bü Ú T½ r (Computer Training Course) CM naj Skill éf¶ cab; epI þ m Start Date 3.fñ ak; bNþ ú HbNþ alCM najkM u Bü Ú T½ r (Computer Training Course) kU detsþ Gtþ elxsi sS Test Code Student ID No. saxa em: AesTu g MTT TY leKak TK Campus cak; GERg CA kU detsþ Gtþ elxsi sS Test Code Student ID No. sareGLi cRtÚ ni c E-mail TOEFL Preparation Course saxa em: AesTu g MTT TY leKak TK Campus cak; GERg CA CM naj Skill éf¶ cab; epI þ m Start Date
Transcript of Final Application Registration 20160629 Final · Final Application_Registration_20160629 Final...
eQµaHCaPasaExµreKatþnam nam
Ex (MMM) éf¶ (DD) qñaM (YYYY)
B½t’manpÞal;xøÜn (Personal Information)
Name in KhmereQµaHCaGkSrLataMgName in Latin
Family Name Given NameePTSex
RbusMale
RsIFemale
eQµaHCaPasaExµreKatþnam nam
Name in KhmereQµaHCaGkSrLataMgName in Latin
Family Name Given Name
éf¶ Ex qñaMkMeNItDate of Birth
elxTUrsBÞTelephone
Gasydæanbc©úb,nñ pÞHelx
Current Address No.pøÚvelxStreet
XuM¼sgáat;Commune/Sangkat
Rsuk¼xNÐDistrict/Khan
extþ¼RkugProvince/City
muxrbrOccupation
m®nþIraCkarGovernment Official
buKÁlikÉkCnEmployee
sisS b¤nisSitStudent
GaCIvkrBusinessperson
buKÁlikGgÁkarNGO Staff
BinÞúScore
kRmitLevel
epSg²Miscellaneous
eQµaH«Buk
B½t’manmatabita b¤GñkGaNaBüa)al (Parents/Guardian Information)
Father’s NameelxTUrsBÞTelephone
eQµaHmþayMother’s Name
muxrbrOccupation
muxrbrOccupation
elxTUrsBÞTelephone
eQµaHGñkGaNaBüa)alGuardian’s Name
GñksmÖasn_Interviewer
htßelxaSignature
GayuAge
smþal;Remark
muxrbrOccupation
elxTUrsBÞTelephone
Gasydæanbc©úb,nñCurrent Address
pÞHelxNo.
dUcxagelISame as above
pøÚvelxStreet
XuM¼sgáat;Commune/Sangkat
Rsuk¼xNÐDistrict/Khan
extþ¼RkugProvince/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 ProgramKid 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.
sßanPaBRKYsarMarital Status
enAlIvSingle
manRKYsarMarried
sBa¢atiNationality
TMB½r1 én2
fñak;1éf¶ suRk1-day Class Fri
fñak;cugs)aþh_ esAr_Weekend Class Sat
éf¶sikSaStudy Day
fñak;5éf¶ cnÞ dl; suRk5-day Class Mon-Fri
fñak;2éf¶2-day Class
cnÞ BuFMon, Wed
GgÁar RBhs,t× Tue, Thu
em:agsikSaStudy Time
em:agsikSaStudy Time
éf¶sikSaStudy Day
cnÞ dl; suRkMon-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)
CMnajSkill
éf¶cab;epIþmStart Date
3.fñak;bNþúHbNþalCMnajkMuBüÚT½r (Computer Training Course)
kUdetsþ GtþelxsisSTest Code Student ID No.
saxa em:AesTugMTT
TYleKakTKCampus
cak;GERgCA
kUdetsþ GtþelxsisSTest Code Student ID No.
sareGLicRtÚnicE-mail
TOEFL Preparation Course
saxa em:AesTugMTT
TYleKakTKCampus
cak;GERgCA
CMnajSkill
éf¶cab;epIþmStart Date
)aT ¼ cas+Yes
eTNo
)aT ¼ cas+Yes
eTNo
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 contacteBlGvtþman 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;?
RelationshipRtUvCa
TelephoneelxTUrsBÞ
´Camatabita b¤GñkGaNaBüa)alsisSxagelIBitCa)anGan nigÉkPaBnUvbTbBaØtþisala ehIysUmGHGagfaB½t’manEdl)anpþl;CUnxagelIBitCaRtwmRtUv.
RelationshipRtUvCa
TelephoneelxTUrsBÞ
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¤edaymUlehtuI 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 describeRbsinebIman sUmerobrab;
A Mengly J. Quach Education.
eQµaHmatabita b¤GñkGaNaBüa)alEdlcUlrYmsmÖas
GñksmÖasn_Interviewer
htßelxaSignature
BinÞúScore
kRmitLevel
smþal;Remark
)aT ¼ cas+Yes
eTNo
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 [email protected], [email protected]
www.aii.edu.kh, www.mjqeducation.edu.kh
Contact Information
sRmab;kareRbIR)as;épÞkñúg (For official use only)
