Disclosure of Information and Proxy Authorization Form

Student Details

To be completed by the Student

Student Full Name(Required)

As per your Passport/ Identification Card (IC)

Student ID(Required)

Example: 700012345

Date of Birth(Required)

Residential Address(Required)

Contact Number(Required)

Student Email(Required)

Example: 700012345@student.curtin.edu.my. NO Personal email.

Authorize Person Details

Full Name of the Authorize Person(Required)

Please provide the name of the person that you authorize to disclose relevant details.

IC No/ Passport Number(Required)

Please provide the authorize person's IC/Passport number

Relationship with Authorize Person(Required)

Parent

Guardian (E.g. Sister/Brother, Uncle/Aunty)

Other

Privacy Statement

Keeping personal data of individual secure is a top priority for us at Curtin Malaysia. In view of the Malaysian Personal Data Protection Act (PDPA) 2010 implemented to safeguard the usage of personal information, you have the right to know the reasons we collect and use the personal information you have provided; how we will use the personal information and whom we may share the personal information with. For details of how the university will use, disclose and protect your personal information, please refer to https://www.curtin.edu.my/wp-content/uploads/2022/09/Curtin-Malaysia-PDPA-2022-.pdf. By agreeing to this form, you are subject to the Student Privacy Notice of the University and have consented to the processing and disclosure of your personal data for the fulfillment of this contract.

Consent(Required)

I agree to the privacy policy.

I hereby authorize Curtin University, Malaysia to disclose relevant details of my application, visa application, enrolment
and academic information at the University for research, sponsorship, employment and other University related
purposes.

I also hereby authorize them to act on my behalf in all matters related to my studies at Curtin University, Malaysia such as Invoice/Payment Receipts, Enrolment enquiry, Student Fees Account enquiry, Award Details enquiry, Result enquiry/ Academic Transcript Collection, Letter Collection, Graduation Tickets/Regalia.

This authorization to perform the actions listed on this form will remain in effect while the student is enrolled in studies at Curtin University, Malaysia.

Disclosure of Information and Proxy Authorization Form

Student Details

Authorize Person Details

Privacy Statement

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