KUOK FOUNDATION BERHAD

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1 KUOK FOUNDATION BERHAD (9641-T) Letter Box No. 110, 16th Floor UBN Tower, 10 Jalan P Ramlee, Kuala Lumpur Tel: Website: 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 rumah (Tetap) Home address (Permanent) Perempuan Taraf perkahwinan Marital status Female surat-menyurat Postal address address 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 Kewarganegaraan Citizenship Bekerja tetap Full-time employment Bangsa Race Bekerja sementara Part-time employment FOR OFFICE USE ONLY RECEIVED: REMARKS: REF. NO.:

2 B BUTIR-BUTIR KURSUS / COURSE DETAILS Kursus dipohon (pilihan pertama) / Sedang dituntut Course applied (first choice) / Attending Nama institusi Name of institution Jangkamasa kursus Duration of course Mula kursus Commencement of course (mm/yyyy) Lokasi institusi Location of institution 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 Sumbangan setahun daripada keluarga / sumber lain. Nyatakan sumber Amount per annum which can be obtained from family / other sources. State sources Jumlah bantuan dipohon setahun Amount applied for per annum C Nama bapa / penjaga Father / Guardian s name No. kad pengenalan NRIC number MAKLUMAT KELUARGA / INFORMATION ON FAMILY Nama ibu Mother s name No. kad pengenalan NRIC number Pendapatan kasar sebulan Gross monthly income Pendapatan kasar sebulan Gross monthly income Kerja sepenuh masa Full-time employment 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. Kerja sepenuh masa Full-time employment 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. Butir - butir SEMUA adik-beradik (kecuali pemohon) Particulars of ALL brothers and sisters (exclude applicant) Nama Name Jantina Gender Taraf perkahwinan Marital status Bil. anak (jika ada) No. of children (if any) (jika menuntut, nyatakan peringkat pendidikan dan nama sekolah / institusi) (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

3 D MAKLUMAT PENDIDIKAN / INFORMATION ON EDUCATION Butir-butir sekolah pemohon pernah belajar Details of schools previously attended by applicant Nama sekolah School name Tahun mula Year commenced Tahun tamat Year completed Keputusan yang dicapai Qualifications obtained E KEPUTUSAN PEPERIKSAAN / EXAMINATION RESULTS SPM /SPVM / O level atau kelayakan yang setaraf dengannya SPM / SPVM / O level or equivalent Mata pelajaran Subject Tahun Year Gred Grade STPM / A level / Matrikulasi atau kelayakan yang setaraf dengannya STPM / A level / Matriculation or equivalent Mata pelajaran Subject Tahun Year 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 Tahun kedua Second year Tahun ketiga Third year Tahun keempat Fourth year F 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

4 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 Year received Pinjaman atau biasiswa Loan or scholarship Nama organisasi / sumber lain Name of organisation / other sources 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? Tahun permohonan Year of application Nombor rujukan, jika ada Reference number, if any Adakah adik-beradik anda menerima bantuan kewangan dari Yayasan Kuok Berhad? Are any of your brothers / sisters assisted by Kuok Foundation Berhad? Jika ada, nyatakan nama adik-beradik If yes, state name of brother / sister Ada Yes Ada Yes Tidak No Jumlah bantuan diterima, jika ada Amount of assistance received, if any Tidak No 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? Jika ada, nyatakan nama adik-beradik If yes, state name of brother / sister Ada Yes Tidak No Institusi sedang dituntut / dipohon Institution attending / applied to H 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) Pertalian dengan pemohon Relationship to applicant Pertalian dengan pemohon Relationship to applicant Jumlah tahun mengenali pemohon No. of years known Jumlah tahun mengenali pemohon No. of years known 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) 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. Tarikh permohonan Date of application Tandatangan pemohon Applicant s signature

5 KUOK FOUNDATION EDUCATIONAL ASSISTANCE DATA FORM PLEASE FILL IN SECTIONS I, II, III, IV, V & VI ONLY FOR OFFICE USE BL CR KIV I I NAME OF APPLICANT RACE SEX APPLICANT S REF. NO. * F / M FINANCIAL STATUS II PARTICULARS OF COURSE TY: YPH: FS: 1. Name of Course REMARKS * Applied / Attending No. of children 2. Name of *University / College / Polytechnic Ranking in family No. studying 3. Course Year (in the coming academic session) Father or : - III EXAMINATION RESULTS (Do not write on shaded boxes) Guardian : Occ - : GY - 1. *SPM / SPVM / O Level results Year Mother : - 1A A+ 3B B+ 7D D : Occ - A 4B B 8E E : GY - 2A A- 5C C+ 9G G 6C C Siblings GY - 2. UEC results Year A1 B3 B5 C7 A2 B4 B6 C8 UEC refers to Unified Examination Certificate for Independent Chinese Secondary Schools in Malaysia. 3. *STPM / A Level results Year A A B- C- D A- C+ R D+ B B+ E C D C B 4. Matriculation results Year 5. MUET results *CGPA / Overall Grade Band 6. Latest *University / College / Polytechnic results Year *CGPA / Overall Grade IV HAVE YOU PREVIOUSLY APPLIED TO KF? If yes, please state year applied : *YES / NO 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 Yes No Remarks 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)

6 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 - A+ Bahasa Inggeris - A- Pendidikan Moral - B Sejarah - A- Mathematics - B Additional Mathematics - C+ Physics - B+ Chemistry - B+ Biology - B+ Bahasa Cina - C+ English for Science - A and Technology TO COMPLETE IN THIS MANNER 1. *SPM / SPVM / O Level results Year A A+ 1 3B B+ 3 7D D A 1 4B B 2 8E E 2A A- 2 5C C+ 2 9G G 6C C 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.

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