KEMENTERIAN AGAMA UNIVERSITAS ISLAM NEGERI MAULANA MALIK IBRAHIM MALANG UPT – PUSAT PENGEMBANGAN BAHASA ENGLISH LANGUAGE CENTER Jl. Gajayana 50 Telp. (0341) 570872 – Fax. (0341) 570872, Kode Pos 65144 REGISTRATION FORM I. Personal Data 1. Name 2. Date of Birth 3. Occupation 4. E-mail 5. Phone Number 6. Recent Address 7. Hometown Address : : : : : : : Photo 3x4 II. Programs taken, check the appropriate box TOEFL ITP IELTS English Language Proficiency Test TOEFL ITP Preparation Course TOEFL IBT Preparation Course IELTS Preparation Course (Part III and IV are filled by admin) III. Additional Information 1. Registration Number : 2. Date of Registration : 3. Date of the Program : 4. Program Fee : Participant, ………………………………. KEMENTERIAN AGAMA UNIVERSITAS ISLAM NEGERI MAULANA MALIK IBRAHIM MALANG UPT – PUSAT PENGEMBANGAN BAHASA ENGLISH LANGUAGE CENTER Jl. Gajayana 50 Telp. (0341) 570872 – Fax. (0341) 570872, Kode Pos 65144 Please attach a copy of KTM/KTP/Passport (Identity Card) --------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------IV. Tanda Bukti Kwitansi No: Sudah terima dari Untuk Pembayaran : …………………………………………………………………… : TOEFL ITP IELTS English Language Proficiency Test TOEFL ITP Preparation Course TOEFL IBT Preparation Course IELTS Preparation Course Jumlah Uang Rp. Peserta, Malang, ……………………20….. Petugas, ………………………………. ………………………………. Note: *Kuitansi harap dibawa pada saat tes dan pengambilan sertifikat * Biaya Program dibayar lunas didepan * Biaya bisa berubah sewaktu waktu Photo 3x4