Year of 2013/14

Intake

Innovation Ambassador Development Programme

Application for Admission
Please complete the application form and submit via email to apply@genovasi.my or
fax +603 7954 0793. Please note that all information provided is strictly confidential.
Only successful applicants will be notified.
The Innovation Ambassador Development Programme is a 10-week programme for
each term of intake. After the completion of the 10-week programme, qualified
participants will have the opportunity to gain practical experience through placement
in Government Ministries, Agencies, GLCs or Corporations.
At this point in time, there is no tuition fee for Malaysians enrolled into the
programme.

Genovasi Foundation (1021192-V)

Lot 2A, Jalan 13/2
46200 Petaling Jaya
Selangor Darul Ehsan
Malaysia
Tel: +603 7954 0628
Fax: +603 7954 0793

www.genovasi.my

PERSONAL INFORMATION

Passport
Picture

Full Name ___________________________________________________

Gender

Male

Female

dd
mm
yyyy Place of Birth ________________________
Birthdate ____/____/____

NRIC/Passport ____________________ Nationality _________________________________

CONTACT INFORMATION
Mailing Address ________________________________________________________________
______________________________________________________________________________
City/Town ______________ Postal Code ______________ State _____________________
Telephone _______________ Mobile _______________ Email _______________________

EDUCATION BACKGROUND
Field(s) of Study _______________________________________________________________
(e.g. Law, Systems Engineering, etc.)

Highest Degree _________________________________ Year of Graduation ______________

(e.g. BSc, MA, PhD)

Currently Studying

Yes

No

Name of University _______________________________

Previous Qualifications (please list all previous university/college degrees)

Degree and Field of Study

Name of University/College

Year of Graduation

_____________________________ ____________________________ _________________

_____________________________ ____________________________ _________________
Languages and Proficiency
Please list languages spoken and indicate proficiency level (native speaker, fluent, good, sufficient, poor)

______________________________________ ______________________________________
______________________________________ ______________________________________

OTHER SKILLS AND INTERESTS

Special Skills
Please list your skills (e.g. mechanical skills, computer skills, software, etc.)

_____________________________________________________________________________
_____________________________________________________________________________
Memberships
Please list any clubs, academic and/or social associations you are a member of
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Honours and Awards

Please name the honours or awards and the supporting organisation
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Motivation
Please describe in a short and plausible manner why you would like to study at Genovasi. What do you personally
expect from the programme for your professional future?
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
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CURRICULUM VITAE
Please include a copy of your curriculum vitae (maximum of 2 pages) as part of the application
form.

CLASS SCHEDULE
The following is our class schedule. Please mark () your preferred choice:
No
1
2
3
4

Class
3A
3B
3C
3D

Class Day 1
Monday
Tuesday
Friday
Saturday

Class Day 2
Thursday
Friday
Saturday
Sunday

Class Hours
9am-5pm
9am-5pm
9am-5pm
9am-5pm

Preference
[ ]
[ ]
[ ]
[ ]

*Please be informed that classes are subject to the number of students registered.

ADDITIONAL INFORMATION
How did you hear about Genovasi?
Website

Facebook

Youtube

Newspaper

Magazine

Friends

Event, please specify: _____________________

Other, please specify: _____________________

T-PROFILE
Looking outside of one's own (academic) box is part of the Innovation Ambassador Development
Programme. Since innovative solutions to complex problems require several disciplines, it is
beneficial for problem solvers to speak different "languages" to ease understanding and allow
for varying points of view. It order for us to attain a better insight not only into your
professional and academic experience, but also your interfacing expertise, inter-disciplinary
skills and projects, we ask you to please complete the T-Profile on the next page.
There is only one rule: The vertical bar must be filled with relevant information about your
academic studies (analytical) and in the horizontal bar, you can map competencies and
activities that transcend or do not relate directly to your field of study (creativity). How and in
what format you do this - as a text, drawing, diagram or photograph is completely up to you.

DECLARATION
I declare that the information provided in the application form is true and correct and that I
have filled in all fields in the application form.

Signature ____________________________________________

Date ________________

SUBMISSION
To submit your application form, you can either:

Submit your application form through our website @ www.genovasi.my

Email your application form to apply@genovasi.my
Mail your application form to the following address:
o Genovasi
o Lot 2A, Jalan 13/2,
o 46200, Petaling Jaya
o Selangor Darul Ehsan