Khazanah Bestari Study Grant Programme 2015

Upper Secondary Form

Personal Particulars
Surname
First Names
Age Date of Birth
Nationality MALAYSIAN I.C No
Race MALAY Place of Birth
Religion ISLAM Gender
Parmanent Home Address
State
Postcode
Tel No (Residence)
Email address

Academic Performance
Name of Present
School
SBP INTEGRASI SELANDAR
Name of Head ENCIK KARIM BIN
BAYOK
Date Started
Address of School SEKOLAH BERASRAMA PENUH INTEGRASI SELANDAR,77500
SELANDAR,MELAKA
PMR Results*


Exam Results Recent Mid-Year Exam Grade* Recent Year-End Exam Grade*
Subject**





Boarding Experience

Position held Dates spent in Boarding Where Boarded







Parents/Guardians
Father/Guardian Mother/Guardian
Name
Occupation
Employer Name -
Monthly Salary*
Telephone Number (mobile)
Email Address - -
No. of Children (including
applicants)

Contact Address



State
Postcode
Signature of Parent
*Please provide supporting document e.g payslip / EA Form
Declaration
I HEREBY DECLARE THAT THE PARTICULARS PROVIDED IN THIS FORM ARE TRUE IN EVERY
RESPECT.
I UNDERSTAND THAT IF ANY OF THESE PARTICULARS GIVEN BY ME ARE FOUND TO BE UNTRUE,
MY APPLICATION WILL AUTOMATICALLY BE DISQUALIFIED.



___________________________________________________

Signature of appliciant Date of application