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: general@kuokfoundation.com Website: www.kuokfoundation.com
Borang permohonan untuk bantuan kewangan pelajaran
Application form for educational assistance
FOR OFFICE USE ONLY
RECEIVED: REF. NO.:
REMARKS:
A MAKLUMAT PEMOHON / PARTICULARS OF APPLICANT
Gambar TERBARU Pemohon
RECENT Photograph
of Applicant
ARAHAN
INSTRUCTIONS
Taip atau tulis dengan jelas. Gunakan HURUF BESAR.
Please type or write clearly. Please use BLOCK LETTERS.
(Sila rujuk Syarat Permohonan yang dilampirkan).
Gariskan nama keluarga anda.
Type or write your name in full as it appears in your NRIC and underline your surname.
borang permohonan.
Tarikh tutup permohonan:
Nama pemohon seperti kad pengenalan
Name of applicant as in NRIC
No. kad pengenalan
NRIC number
Taraf perkahwinan
Marital status
Alamat rumah (Tetap)
Home address (Permanent)
No. telefon rumah
Home telephone no.
No. telefon bimbit
Handphone no.
Alamat e-mail
E-mail address
Alamat surat-menyurat
Postal address
Tarikh dan tempat lahir
Date and place of birth
Umur
Age
Kewarganegaraan
Citizenship
Bangsa
Race
Menuntut sepenuh masa
Studying full-time
Bekerja tetap
Full-time employment
Bekerja sementara
Part-time employment
Kedudukan sekarang pada masa pemohonan
Present status at time of application
Poskod
Postal code
Poskod
Postal code
Bandar dan Negeri
City and State
Bandar dan Negeri
City and State
Lelaki
Male
Perempuan
Female
B BUTIR-BUTIR KURSUS / COURSE DETAILS
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
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)
C MAKLUMAT KELUARGA / INFORMATION ON FAMILY
Butir - butir SEMUA adik-beradik (kecuali pemohon)
Particulars of ALL brothers and sisters (exclude applicant)
Nama
Name
Jantina
Gender
Umur
Age
Taraf
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
Kerja sepenuh masa
Full-time employment
Kerja separuh masa
Part-time employment
Perniagaan sendiri
Own business
Bersara
Retired
Nama bapa / penjaga
Father / Guardians name
Nama ibu
Mothers name
No. kad pengenalan
NRIC number
Umur
Age
No. kad pengenalan
NRIC number
Umur
Age
Alamat
Address
No. telefon rumah
Home telephone no.
No. telefon bimbit
Handphone no.
Poskod
Postal code
Bandar dan Negeri
City and State
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.
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.
Pekerjaan
Occupation
Pendapatan kasar sebulan
Gross monthly income
Alamat
Address
Poskod
Postal code
Bandar dan Negeri
City and State
No. telefon rumah
Home telephone no.
No. telefon bimbit
Handphone no.
Pekerjaan
Occupation
Pendapatan kasar sebulan
Gross monthly income
No. telefon pejabat
Office telephone no.
No. telefon pejabat
Office telephone no.
D MAKLUMAT PENDIDIKAN / INFORMATION ON EDUCATION
E KEPUTUSAN PEPERIKSAAN / EXAMINATION RESULTS
F PENCAPAIAN KO-KURIKULUM / CO-CURRICULAR ACHIEVEMENTS
Butir-butir sekolah pemohon pernah belajar
Details of schools previously attended by applicant
Nama sekolah
School name
Bandar dan Negeri
City and State
Tahun mula
Year commenced
Tahun tamat
Year completed
Keputusan yang dicapai
Qualifications obtained
Mata pelajaran
Subject
SPM /SPVM / O level atau kelayakan yang setaraf dengannya
SPM / SPVM / O level or equivalent
Mata pelajaran
Subject
Gred
Grade
Tahun
Year
STPM / A level / Matrikulasi atau kelayakan yang setaraf dengannya
STPM / A level / Matriculation or equivalent
Gred
Grade
Tahun
Year
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
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
I LAIN-LAIN MAKLUMAT / OTHER INFORMATION
H MAKLUMAT PERUJUK / INFORMATION OF REFEREES
Ada
Yes
Tidak
No
Ada
Yes
Tidak
No
Ada
Yes
Tidak
No
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
Jumlah bantuan diterima, jika ada
Amount of assistance received, 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
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
Institusi sedang dituntut / dipohon
Institution attending / applied to
Nama (Encik / Cik / Puan)
Name (Mr / Miss / Mrs / Madam)
Alamat
Address
No. telefon rumah
Home telephone no.
No. telefon bimbit
Handphone no.
Poskod
Postal code
Bandar dan Negeri
City and State
Pekerjaan
Occupation
Alamat
Address
Poskod
Postal code
Bandar dan Negeri
City and State
No. telefon rumah
Home telephone no.
No. telefon bimbit
Handphone no.
Pekerjaan
Occupation
No. telefon pejabat
Office telephone no.
Pertalian dengan pemohon
Relationship to applicant
No. telefon pejabat
Office telephone no.
Pertalian dengan pemohon
Relationship to applicant
Jumlah tahun mengenali pemohon
No. of years known
Jumlah tahun mengenali pemohon
No. of years known
Nama (Encik / Cik / Puan)
Name (Mr / Miss / Mrs / Madam)
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 applicants family for a period of not less than 3 years. Referees can be relatives or close family friends BUT not
applicants own parents, brothers / sisters or fellow students. Referees should be contactable by telephone during office hours.
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
Applicants signature
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 APPLICANTS 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 : Age -
III EXAMINATION RESULTS (Do not write on shaded boxes) Guardian : Occ -
: GY -
1. *SPM / SPVM / O Level results Year
Mother : Age -

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
D
B-
R
C-
A- C+ 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? *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 Yes

No Remarks


1. University / College / Polytechnic acceptance letter

2. Parents / Guardians 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 / Guardians identity cards or death certificate, if deceased

11. School leaving certificates


12. School testimonials (if any)



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 Foundations 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 TO COMPLETE IN THIS MANNER

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
1. *SPM / SPVM / O Level results Year 2009


1A
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.