Name:
Date of birth: / Place of birth: / Age:
Citizenship: / I/C No:
Permanent address:
E-mail Address:
House telephone no: / Handphone no:
Are any of your parents an employee of Bursa Malaysia?
Yes. Name: ______
No
How do you come to know about the Yayasan Bursa Malaysia Scholarship?
Newspaper
Bursa Malaysia website
Word-of-mouth/ Friends/Relatives
Others (please specify): ______
B. Academic Details– Please tick ()
STPM / A-LEVELS / MATRICULATION / FOUNDATION
SCHOOL/INSTITUTION:
YEAR TAKEN:
SUBJECT / GRADE / SUBJECT / GRADE
Malaysian University English Test (MUET): Band ______
Cumulative Grade Point Average (CGPA):
Sem. 1 / Sem. 2 / Sem. 3 / Sem. 4
SPM / Year:
SUBJECT / GRADE / SUBJECT / GRADE
GCE ‘O’ Level English (1119): Grade ______
C. Extra-Curricular Activities - Please tick ()
Represented
Sports / School / University
/college / District / State / Country
Role
Uniform troop/Association/Club / Member / Treasurer / Secretary / Vice
President / President / Ad-hoc Committee
D. Scholarship History- Please tick ()
Have you received any scholarship before? Yes No
If yes, please provide details:
Sponsor Organization / Duration / Value
(RM/Year)
Are you currently bondedto any scholarship agreement? Yes No
E. Course/Programme Details Applied for this Scholarship
Programme of study
(eg: Bachelor In Accountancy)
Name of institution
(eg: Universiti Malaya)
Commencement date/ session
(eg: 1/8/12 / Semester I, 2012/2013)
Duration of study
(eg: 4 years)
Expected graduation date:
(eg: August 2016)
F. Details of Father / Guardian
Name:
Citizenship: / New I/C no:
Old I/C no:
Date of birth: / Place of birth:
House tel no: / Hand phone no:
Occupation: / Monthly income:
Name & address of employer: / Signature:
G. Details of Mother / Guardian
Name:
Citizenship: / New I/C no:
Old I/C no:
Date of birth: / Place of birth:
House tel no: / Hand phone no:
Occupation: / Monthly income:
Name & address of employer: / Signature:
H. Details of Siblings
No. / Name / Age / Date of
birth / Occupation/ Student / Employer/School
1
2
3
4
5
6
7
8
Declaration
I hereby declare that all information furnished above are accurate and true to the best of my belief andYayasan BursaMalaysia reserves its rights to terminate/withdraw this application should any information furnished be discovered as inaccurate and untrue.
Name: / Applicant’s Signature:
Date:
* To be Completed By Employer of Parent/ Guardian/ Headmaster/ Principal/ Penghulu/ Government Officer within the home vicinity
I hereby verify that all information furnished above are accurate and true to my knowledge.
Name:
Designation: / Signature:
Date:
Official stamp:
Note (*): If any of the parents is an employee of Bursa Malaysia Bhd, this section must be completed by Head ofDepartment/Section.
FOR OFFICE USEDate received: / Signature:
Note: Please check the availability and verification of the following documents and attached them with your submission. / Please tick( )
1. / Copy of I/Cs ofapplicant and parents/guardian
2. / Copy of examination results
3. / Copy of co-curricular activities certificates/ testimonials
4. / Copy of Offer Letter from institution of higher learning (if available)
5. / Latest copy of parents/guardian salary slip
Yayasan Bursa Malaysia Scholarship Programme
Scholarship Application Form 2015/2016
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