maklumat pemohon / particulars of applicant

KUOK FOUNDATION BERHAD
(9641-T)
Letter Box No. 110, 16th Floor UBN Tower, 10 Jalan P Ramlee, 50250 Kuala Lumpur
Tel: 03 - 2711 8428 E-mail: [email protected] Website: www.kuokfoundation.com
Borang permohonan untuk bantuan kewangan pelajaran
Application form for educational assistance
ARAHAN
INSTRUCTIONS
Taip atau tulis dengan jelas. Gunakan HURUF BESAR.
Please type or write clearly. Please use BLOCK LETTERS.
Gariskan nama keluarga anda.
Type or write your name in full as it appears in your NRIC and underline your surname.
Gambar TERBARU Pemohon
borang permohonan.
RECENT Photograph
of Applicant
(Sila rujuk Syarat Permohonan yang dilampirkan).
Tarikh tutup permohonan:
A
MAKLUMAT PEMOHON / PARTICULARS OF APPLICANT
Nama pemohon seperti kad pengenalan
Name of applicant as in NRIC
No. kad pengenalan
NRIC number
Lelaki
Male
Alamat rumah (Tetap)
Home address (Permanent)
Perempuan Taraf perkahwinan
Marital status
Female
Alamat surat-menyurat
Postal address
Poskod
Postal code
Bandar dan Negeri
City and State
No. telefon rumah
Home telephone no.
No. telefon bimbit
Handphone no.
Bandar dan Negeri
City and State
Alamat e-mail
E-mail address
Umur
Age
Tarikh dan tempat lahir
Date and place of birth
Kedudukan sekarang pada masa pemohonan
Present status at time of application
Menuntut sepenuh masa
Studying full-time
Poskod
Postal code
Kewarganegaraan
Citizenship
Bekerja tetap
Full-time employment
Bangsa
Race
Bekerja sementara
Part-time employment
FOR OFFICE USE ONLY
RECEIVED:
REMARKS:
REF. NO.:
B
BUTIR-BUTIR KURSUS / COURSE DETAILS
Kursus dipohon (pilihan pertama) / Sedang dituntut
Course applied (first choice) / Attending
Nama institusi
Name of institution
Lokasi institusi
Location of institution
Jangkamasa kursus
Duration of course
Mula kursus
Commencement of course (mm/yyyy)
Tamat kursus
Completion of course (mm/yyyy)
Butir - butir perbelanjaan diperlukan setahun (nyatakan dalam Ringgit Malaysia)
Breakdown of estimated expenses required per annum (in Malaysian Ringgit)
Yuran kursus
Tuition fees
Yuran lain
Other fees
Tempat tinggal
Accomodation
Makanan
Food
Perbelanjaan lain
Other expenditure
Jumlah
Total
Bilangan tahun bantuan diperlukan
No. of years assistance required
0
Sumbangan setahun daripada keluarga / sumber lain. Nyatakan sumber
Amount per annum which can be obtained from family / other sources. State sources
C
Jumlah bantuan dipohon setahun
Amount applied for per annum
MAKLUMAT KELUARGA / INFORMATION ON FAMILY
Nama bapa / penjaga
Father / Guardian’s name
Nama ibu
Mother’s name
No. kad pengenalan
NRIC number
Umur
Age
No. kad pengenalan
NRIC number
Alamat
Address
Alamat
Address
Kerja sepenuh masa
Full-time employment
No. telefon rumah
Home telephone no.
Pekerjaan
Occupation
No. telefon bimbit
Handphone no.
Pendapatan kasar sebulan
Gross monthly income
Kerja separuh masa
Part-time employment
Perniagaan sendiri
Own business
Poskod
Postal code
Bandar dan Negeri
City and State
Poskod
Postal code
Bandar dan Negeri
City and State
No. telefon rumah
Home telephone no.
Pekerjaan
Occupation
Umur
Age
Bersara
Retired
Nama dan alamat majikan / perniagaan sendiri. Jika sudah bersara, nyatakan nama dan
alamat majikan / perniagaan sendiri yang terdahulu.
Name and address of employer / own business. If retired, state name and address of
previous employer / own business.
Kerja sepenuh masa
Full-time employment
No. telefon bimbit
Handphone no.
Pendapatan kasar sebulan
Gross monthly income
Kerja separuh masa
Part-time employment
Perniagaan sendiri
Own business
Bersara
Retired
Nama dan alamat majikan / perniagaan sendiri. Jika sudah bersara, nyatakan nama dan
alamat majikan / perniagaan sendiri yang terdahulu.
Name and address of employer / own business. If retired, state name and address of
previous employer / own business.
No. telefon pejabat
Office telephone no.
No. telefon pejabat
Office telephone no.
Butir - butir SEMUA adik-beradik (kecuali pemohon)
Particulars of ALL brothers and sisters (exclude applicant)
Nama
Name
Jantina Umur Taraf
Gender Age
perkahwinan
Marital status
Bil. anak
(jika ada)
No. of
children
(if any)
Pekerjaan (jika menuntut, nyatakan
peringkat pendidikan dan nama
sekolah / institusi)
Occupation (If studying, state level
of education and name of school /
institution)
No. telefon (rumah,
bimbit atau pejabat)
Telephone no.
(home, handphone
or office)
Pendapatan
kasar sebulan
Gross monthly
income
D
MAKLUMAT PENDIDIKAN / INFORMATION ON EDUCATION
Butir-butir sekolah pemohon pernah belajar
Details of schools previously attended by applicant
Nama sekolah
School name
E
Bandar dan Negeri
City and State
Tahun mula
Tahun tamat
Keputusan yang dicapai
Year commenced Year completed Qualifications obtained
KEPUTUSAN PEPERIKSAAN / EXAMINATION RESULTS
SPM /SPVM / ‘O’ level atau kelayakan yang setaraf dengannya
SPM / SPVM / ‘O’ level or equivalent
Tahun
Year
STPM / ‘A’ level / Matrikulasi atau kelayakan yang setaraf dengannya Tahun
STPM / ‘A’ level / Matriculation or equivalent
Year
Mata pelajaran
Subject
Gred
Grade
Mata pelajaran
Subject
Gred
Grade
Keputusan peperiksaan universiti / kolej / politeknik seperti gred keseluruhan / purata nilai gred kumulatif, jika ada
University / college / polytechnic examination results such as overall grades / cumulative grade point average, if applicable
Tahun pertama
First year
F
Tahun kedua
Second year
Tahun ketiga
Third year
Tahun keempat
Fourth year
PENCAPAIAN KO-KURIKULUM / CO-CURRICULAR ACHIEVEMENTS
Aktiviti-aktiviti semasa di sekolah / politeknik / kolej / universiti dan jawatan yang disandang
Activities in school / polytechnic / college / university and leadership positions held
Anugerah / hadiah yang dimenangi seperti pencapaian akademik, sukan dan pertandingan lain di sekolah / politeknik / kolej / universiti
Prizes / awards won such as academic / subject prizes, trophies, medals for sports / other competitions in school / polytechnic / college / university
G
BANTUAN KEWANGAN / FINANCIAL ASSISTANCE
Butir-butir bantuan termasuk pinjaman yang anda terima terdahulu dan sekarang, jika ada, oleh organisasi-organisasi atau sumber-sumber lain
Details of past and present assistance including loans, if any, received from other organisations or other sources
Tahun diterima Pinjaman atau biasiswa Nama organisasi / sumber lain
Name of organisation / other sources
Year received Loan or scholarship
Jumlah setahun
Amount per annum
Namakan organisasi lain yang anda pernah memohon biasiswa / pinjaman
Name other organisations you have applied to for scholarship / loan
Pernahkah anda memohon bantuan kewangan dari Yayasan Kuok Berhad sebelum ini?
Have you previously applied to the Kuok Foundation Berhad?
Ada
Yes
Tahun permohonan
Year of application
Jumlah bantuan diterima, jika ada
Amount of assistance received, if any
Nombor rujukan, jika ada
Reference number, if any
Tidak
No
Adakah adik-beradik anda menerima bantuan kewangan dari Yayasan Kuok Berhad?
Are any of your brothers / sisters assisted by Kuok Foundation Berhad?
Ada
Yes
Jika ada, nyatakan nama adik-beradik
If yes, state name of brother / sister
Tahun, jenis bantuan atau nombor rujukan kami
Year assisted, type of award or our reference number
Adakah adik-beradik anda memohon bantuan kewangan dari Yayasan Kuok Berhad pada tahun ini?
Have any of your brothers / sisters also applied to Kuok Foundation Berhad this year?
Ada
Yes
Jika ada, nyatakan nama adik-beradik
If yes, state name of brother / sister
Institusi sedang dituntut / dipohon
Institution attending / applied to
H
Tidak
No
Tidak
No
MAKLUMAT PERUJUK / INFORMATION OF REFEREES
Namakan dua perujuk yang mengenali pemohon dan keluarga pemohon sekurang-kurangnya 3 tahun. Perujuk boleh terdiri daripada saudara mara atau kawan rapat keluarga TETAPI
bukan daripada kalangan penuntut, ibubapa atau adik-beradik pemohon. Perujuk mestilah boleh dihubungi melalui telefon semasa waktu pejabat.
Name of two (2) referees who are known to the applicant and applicant’s family for a period of not less than 3 years. Referees can be relatives or close family friends BUT not
applicant’s own parents, brothers / sisters or fellow students. Referees should be contactable by telephone during office hours.
Nama (Encik / Cik / Puan)
Name (Mr / Miss / Mrs / Madam)
Nama (Encik / Cik / Puan)
Name (Mr / Miss / Mrs / Madam)
Alamat
Address
Alamat
Address
Bandar dan Negeri
City and State
Poskod
Postal code
Poskod
Postal code
Bandar dan Negeri
City and State
No. telefon rumah
Home telephone no.
No. telefon bimbit
Handphone no.
No. telefon rumah
Home telephone no.
No. telefon bimbit
Handphone no.
Pekerjaan
Occupation
No. telefon pejabat
Office telephone no.
Pekerjaan
Occupation
No. telefon pejabat
Office telephone no.
Jumlah tahun mengenali pemohon
No. of years known
Pertalian dengan pemohon
Relationship to applicant
Jumlah tahun mengenali pemohon
No. of years known
Pertalian dengan pemohon
Relationship to applicant
I
LAIN-LAIN MAKLUMAT / OTHER INFORMATION
Kenyataan lain untuk menyokong permohonan ini (contohnya kenapa ibubapa tidak mampu membiayai perbelanjaan pelajaran anda)
Other relevant information to support your application (e.g. why parents cannot afford your educational expenses)
1. Saya mengakui bahawa maklumat yang diberikan adalah benar dan saya tidak dengan sengaja menyembunyikan apa-apa maklumat yang dikehendaki
untuk permohonan ini.
I hereby declare that the information given in this form is true to the best of my knowledge and that I have not wilfully suppressed any material fact
relevant to this application.
2. Saya dengan ini memberi persetujuan untuk pengumpulan, perakaman, penyimpanan dan penggunaan data peribadi saya bagi tujuan memproses
permohonan ini dan juga untuk kegunaan pentadbiran seterusnya yang melibatkan apa-apa bantuan kewangan yang ditawarkan kepada saya, termasuk
tetapi tidak terhad kepada mana-mana kegunaan lain berkaitan dengan bantuan kewangan ini.
I hereby give consent for the collection, recording, retention, storage and use of my personal data for the purpose of processing this application and
subsequent administration of any study award offered to me, including but not limited to any other uses in connection with the study award.
Tarikh permohonan
Date of application
Tandatangan pemohon
Applicant’s signature
KUOK FOUNDATION EDUCATIONAL ASSISTANCE – DATA FORM
FOR OFFICE USE
PLEASE FILL IN SECTIONS I, II, III, IV, V & VI ONLY
I
NAME OF APPLICANT
II
PARTICULARS OF COURSE
RACE
SEX
M
F
1. Name of Course
Applied
Attending
2. Name of *University / College / Polytechnic
BL
APPLICANT’S REF. NO.
FINANCIAL STATUS
TY:
YPH:
REMARKS
CR KIV
I
FS:
No. of children
Ranking in family
No. studying
3. Course Year (in the coming academic session)
Father or : Age Guardian : Occ : GY -
III EXAMINATION RESULTS (Do not write on shaded boxes)
1. *SPM / SPVM / ‘O’ Level results
Year
Mother
1A
2A
A+
A
A-
2. UEC results
3B
4B
5C
6C
B+
B
C+
C
7D
8E
9G
D
E
G
: Age : Occ : GY -
Siblings’ GY
-
0
Year
A1
A2
B3
B4
B5
B6
C7
C8
UEC refers to Unified Examination Certificate for Independent Chinese Secondary Schools in Malaysia.
3. *STPM / ’A’ Level results
A
B
C
A
AB+
B
4. Matriculation results
Year
D
E
BC+
C
Year
R
CD+
D
5. MUET results
*CGPA / Overall Grade
Band
6. Latest *University / College / Polytechnic results
Year
*CGPA / Overall Grade
IV HAVE YOU PREVIOUSLY APPLIED TO KF?
YES
NO
If yes, please state year applied :
V
ARE ANY OF YOUR * BROTHERS / SISTERS ASSISTED BY KF?
If yes, state his / her name :
VI HAVE ANY OF YOUR * BROTHERS / SISTERS ALSO APPLIED TO KF THIS YEAR?
If yes, please state his / her name :
Note: KF refers to Kuok Foundation Berhad and * delete whichever is not applicable
Please turn over to next page for instructions
DOCUMENTS CHECKLIST
(Please arrange your documents according to the order below)
PLEASE tick ( √ ) either “Yes” or “No”. If “No” please explain why under “Remarks”
Have you enclosed certified copies of
1.
University / College / Polytechnic acceptance letter
2.
Parents’ / Guardian’s proof of income for the past 2 years
3.
Brothers’ and sisters’ proof of income for the past 2 years, if they are working
4.
Letters or documents to prove that brothers and sisters are pursuing higher
education in universities / colleges / institutions
5.
University / College / Polytechnic results (Actual/Forecast)
6.
STPM / ‘A’ Level / Matriculation / Foundation (Actual/Forecast) & MUET results
7.
SPM / SPVM / ‘O’ Level / UEC results (Actual/Forecast)
8.
Identity card and birth certificate of applicant
9.
Birth certificates of all brothers and sisters
10. Parents’ / Guardian’s identity cards or death certificate, if deceased
11. School leaving certificates
12. School testimonials (if any)
Yes
No
Remarks
INSTRUCTIONS
PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY BEFORE FILLING
DATA FORM
1. Please write or type clearly in BLOCK LETTER and complete DATA FORM in ENGLISH.
2. Please state “NA” in those sections which are not applicable to you.
3. The DATA FORM should be attached to the front page of the Kuok Foundation’s official
application forms.
4. In SECTION II, Nos. 1 & 2 you should state only your first choice of course and
university / college / polytechnic, if you are waiting for acceptance into university /
college / polytechnic.
5. In SECTION II, No. 3, “Course Year” refers to whether you are in Year 1, 2 etc. in
the new academic session.
6. In SECTION III, Nos. 1, 2 & 3, please state number of distinctions or credits or passes
obtained, for example :
SPM RESULTS 2009
Bahasa Melayu
Bahasa Inggeris
Pendidikan Moral
Sejarah
Mathematics
Additional Mathematics Physics
Chemistry
Biology
Bahasa Cina
English for Science
and Technology
TO COMPLETE IN THIS MANNER
A+
AB
AB
C+
B+
B+
B+
C+
A
1. *SPM / SPVM / ‘O’ Level results
1A
2A
A+
A
A-
1
1
2
3B
4B
5C
6C
B+
B
C+
C
3
2
2
Year
7D
8E
9G
2009
D
E
G
7. Please ensure that all sections of the application form have been completed. Incomplete
application will be disqualified.
DEADLINE FOR SUBMISSION OF DOCUMENTS
If any of the documents are not immediately available, please submit them within 1 month
from the closing date for application.