APPLICATION FORM FOR SCIENCE & TECHNOLOGY DOCTORAL & POSTDOCTORAL SCHOLARSHIPS


Recent

Photograph

A. PERSONAL PARTICULARS
Please select types of scholarship
(Please √ appropriatebox) /
Doctoral Postdoctoral
Name asper NRIC / NRICnumber
Home address(Permanent) / Postaladdress
Home telephone no. / Handphoneno. / Current telephoneno. / E-mail address
Date andplace of birth / Age / Gender / Race / Citizenship
Languages / Spoken / Written
Current status
(Please √ appropriatebox) / Master / PhD Employed Unemployed / Marital status
B. EDUCATION (Includinganyotherprofessional/nonprofessionalqualifications)
EducationalInstitutions attended
(Secondaryschool onwards) / From
(year) / To
(year) / Qualifications obtained
TERTIARY LEVEL EDUCATION
Institution / Date Enroll / Date Graduate / CGPA
RESULT OF POSTGRADUATE /PROFESSIONALQUALIFICATIONS (if any,including CLP/ BarFinalsetc.)
C. DETAILS OFINTENDED COURSE
Typeof programme
(Please √ appropriatebox) / ResearchCourseworkBothresearch & coursework
Course status
(Please √ appropriatebox) /
AttendingAcceptedAppliedIntendtoapply
Department / Faculty / University / Institution
Duration ofcourse
Min: yearsMax: years / Date of commencement ofcourse / Expecteddateof completionof course
TITLEOF RESEARCH PROPOSAL(if applicable)
COURSEWORK SUBJECTS(if applicable)
RESEARCHEXPERIENCE (Pleaseprovide anoutlineofprevious research workperformed,dissertation,graduation exercise, papers publishedorpresentedat conferencesetc.)
(continueon separate sheet ifnecessary)
D. BREAKDOWN OF ESTIMATED EXPENSES REQUIRED PER ANNUM(in RM)
Tuition fees / Other fees / Accommodation
Food / Otherexpenditure / Total
Amountper annumwhichcan be obtained fromfamily/othersources.Statesources.
Shortfall (if any) / No.of years assistance required
E. PARTICULARS OF FAMILY
SPOUSE
(if married) / FATHER / MOTHER
Name
Age
Occupation
Grossincome per month
Telephonenumber
(home/handphone/office)
Name andaddress of employer
(if retired, state previous employment)
No.ofchildren and their ages(if applicable)
PARTICULARS OF SIBLINGS
Name / Gender / Age / Occupation / Telephonenumber
(house/handphone/office)

(continueon separate sheet ifnecessary)

F. PRESENT & PAST WORKING EXPERIENCE
(Pleaselist inchronologicalorderall workingexperiencewhetherpaidorunpaid)
Position held / From
(mm/yy) / To
(mm/yy) / Institution/Organization / Salary
(if any)

(continueon separate sheet ifnecessary)

G.GENERAL
DETAILSOFPASTAND PRESENTSCHOLARSHIPS/ LOANS/BURSARIESIFANY, RECEIVED FROM OTHER ORGANISATIONSOR OTHER SOURCES
Year received / Scholarship/Loan / Bursary / Name of organization/ source / Amountper annum
EXTRA-CURRICULAR / SPORTINGACTIVITIES(Please state thehighest level ofparticipation)
(continueon separate sheet ifnecessary)
DETAILSOFTRAVELABROAD(if any)
(continueon separate sheet ifnecessary)
OTHER RELEVANT INFORMATION TO SUPPORT YOUR APPLICATION
(continueon separate sheet ifnecessary)
H.REFEREES
NAMESOF TWO REFEREES TO WHOM REFERENCE MAY BEMADE
Refereesnamedshould haveknownthe applicantand/or theapplicant’sfamily for period of not less than (3) years.
Name
(Mr/Ms/Mdm) / Name
(Mr/Ms/Mdm)
Address / Address
Home tel. no. / Handphoneno. / Home tel. no. / Handphoneno.
Occupation / Office tel. no. / Occupation / Office tel. no.
No. ofyears known / Relationshipto applicant / No. ofyears known / Relationshipto applicant

I.DECLARATION

Iherebydeclare that the information given inthis form is true tothe bestof my knowledgeandthatIhavenot willfully suppressed any material fact relevant tothisapplication.

DateofapplicationApplicant’ssignature