APPLICATION FOR SCHOLARSHIP YEAR 2015

(FOR MALAYSIAN STUDENTS)

SECTION A – PERSONAL INFORMATION

1. / Name per I/C / :
2. / I.C. No / :
3. / University/ College/ School/ Faculty / : / UPM
4. / Level of Study/ Course of Study/ Year of Study / :
5. / Student Reg. No. / :
6. / Gender / :
7. / Date of Birth (dd-mm-yyyy) / :
8. / Religion / :
9. / Nationality / :
10. / Permanent Address / :
11. / Temporary Address / :
12. / Telephone No / :
13. / Mobile Phone No / :
14. / Email Address / :

SECTION B – PARENTS / GUARDIAN INFORMATION

1. / Name of Applicant’s Father / :
2. / I.C. No / :
3. / Occupation/Position / :
4. / Marital Status / : / Married / Divorced / Separated / Deceased *
5. / Monthly Income (RM) / :
6. / Income from Other Source (RM) / :
1. / Name of Applicant’s Mother / :
2. / I.C. No / :
3. / Occupation/Position / :
4. / Marital Status / : / Married / Divorced / Separated / Deceased *
5. / Monthly Income (RM) / :
6. / Income from Other Source (RM) / :
1. / Name of Applicant’s Guardian / :
2. / I.C. No / :
3. / Occupation/Position / :
4. / Marital Status / : / Married / Single / Divorced / Separated / Deceased *
5. / Monthly Income (RM) / :
6. / Income from Other Source (RM) / :

i) Did you ever receive any academic award and Book Prize? If so, kindly state the details and date of receipt.

No. / Detail(s) / Date of Receipt
1.
2.
3.

* Delete whichever not applicable

SECTION C– SIBLING(S) INFORMATION

If working / If studying
Name / Relationship / Age / Occupation / Monthly Income (RM) / Level / Name of
School/ Institution/ College/ University

SECTION D – FINANCIAL INFORMATION

1. List sources of financial support for your studies in the University and indicate amount:

Source(s) / Amount (RM)

2. Do your parents own a house?

r YES r NO

If Yes, kindly specify

Type of House:
(e.g. Double Storey Terrace)
Address:

3. Have you APPLIED to any other source for financial assistance for the current year?

r YES r NO

If Yes, specify:

Scholarship / Loan / Award / Date of Applied


4. Have you ever been AWARDED any bursary, scholarship/loan or financial assistance from the University or any other source?

r YES r NO

If Yes, specify

Scholarship / Loan / Award / Date of Applied

SECTION E – REFEREES

1. Names and addresses of two referees, from whom information about you may be obtained.

Referee 1
Name / :
Relationship / :
Occupation / :
Address / :
Contact No / :
Referee 2
Name / :
Relationship / :
Occupation / :
Address / :
Contact No / :

SECTION F – DECLARATION BY STUDENT

I affirm that the above information is complete, true and correct, and understand that if I am offered the loan, the University reserves the right to withdraw the offer when at any stage; it is found that the information given is Incorrect or if, in the opinion of the University, I have failed to make satisfactory progress in my studies or disciplinary action has been taken against me by the University.

Date: Signature:

Name :

NRIC :

Applicant’s Self Checklist:

q a) 1 certified true copy of applicant’s I/C.

q b) 1 certified true copy of applicant’s parents &/or guardian income payment slip or EA form.

q c) 1 certified true copy of applicant’s SPM result/ UEC result/ STPM result.

q d) 1 certified true copy of applicant’s offer letter &/ or student bill.

q e) Any other supporting document, etc.

SAMPLE

Name (as per I/C):

Summary of Examination Results:

PMR / SPM/ UEC/ O-level / STPM/ A-level
NIL
FOUNDATION / DEGREE / OTHERS