ENGLISH FOR ACADEMIC SUCCESS FORM

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Building 39A+B, Street 592, Sangkat Boeung Kak 2, Khan Toul Kork, Phnom Penh, Cambodia.
Tel: 070 592 888 / 017 592 888 I www.ute.ac I info@ute.ac

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PROGRAM SELECTION

1. PROGRAM APPLIED FOR: THE ENGLISH FOR ACADEMIC SUCCESS (EAS) PROGRAM
2. TIME OF STUDY (Mon-Wed-Thus)
3. TIME OF STUDY (Tue-Thu)

PERSONAL DATA

Please complete all sections using BLOCK LETTERS.

FULL NAME IN ENGLISH (as in NID/Passport)
GENDER
MARITAL STATUS
CURRENT ADDRESS

EDUCATION RECORD

ENGLISH LANGUAGE PROFICIENCY

Please specify your current English language proficiency

EMERGENCY CONTACT

PARENTS/GUARDIAN INFORMATION (Please provide both father and mother or guardian information)

HOW DO YOU KNOW ABOUT UTE?

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UTE STUDENT AMBASSADOR

I declare that all the information provided in the application is true according to my knowledge. I am aware that if I deliberately convey wrong information or mislead the university, I will be kept accountable under the law for my actions.

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