ENGLISH PLACEMENT TEST APPLICATION FORM Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. 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 PERSONAL DATA Please complete all sections using BLOCK LETTERS. FULL NAME IN ENGLISH (as in NID/Passport) *FirstLastGENDER *MaleFemaleDATE OF BIRTH *FULL NAME IN KHMER (as in NID/Passport) *NATIONALITY *PLACE OF BIRTH *CONTACT NUMBER *MARITAL STATUS *SingleMarriedEMAIL ADDRESSTEST INFORMATION- Current Level of Study: First ChoiceSecond ChoiceThird Choice-Other (please specify):-- Major/Field of Study (if application): Single Line Text- Preferred Time of Study: CheckboxesMorningAfternoonEveningWeekend (Sat-Sunday)- Purpose of Test: Checkboxes (copy)Entrance to Higher Education-Other (please specify):Checkboxes (copy) (copy)Placement to a Language Course- PLACE TEST NAME - Preferred Test Date: TEST DATE *- Preferred Test Time: CheckboxesMorningAfternoon HOW DO YOU KNOW ABOUT UTE? SelectTV/RADIOOPEN HOUSECAMPUS VISITEDUCATION FAIRSCHOOL TALKSOCIAL MEDIAUTE STUDENT AMBASSADORUTE STUDENT AMBASSADOR - NAMEName * DECLARATION BY STUDENT I hereby confirm that the information provided above is true and accurate to the best of my knowledge. I understand that my personal data will be used solely for the purpose of administering the Cambridge English Placement Test. I agree to comply with the rules and regulations of the test as outlined by the institution. NAME OF SIGNATUREDATE OF SIGNATURE_________________________________ SIGNATURE OF APPLICANT Submit