YAYASAN BURSA MALAYSIA SCHOLARSHIP PROGRAMME

Scholarship Application Form 2014/2015

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A. Personal Particulars
Name:
Date of birth:
Citizenship:

Place of birth:

Age:

I/C No:

Permanent address:

E-mail Address:
House telephone no:

Hand phone no:

Are any of your parents an employee of Bursa Malaysia?

Yes. Name: ___________________________________________
No
How do you come to know about the Yayasan Bursa Malaysia Scholarship?
Newspaper
Bursa Malaysia website
Word-of-mouth/ Friends/Relatives
Others (please specify): __________________________________

Yayasan Bursa Malaysia Scholarship Programme

Scholarship Application Form 2014/2015
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B. Academic Details Please tick ( )

STPM

A-LEVELS

MATRICULATION

FOUNDATION

SCHOOL/INSTITUTION:
YEAR TAKEN:
SUBJECT

GRADE

SUBJECT

GRADE

Malaysian University English Test (MUET): Band _______

Cumulative Grade Point Average (CGPA):
Sem. 1
Sem. 2

Sem. 3

SPM

Year:

SUBJECT

GRADE

SUBJECT

Sem. 4

GRADE

GCE O Level English (1119): Grade _______

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C. Extra-Curricular Activities - Please tick ( )

Represented
Sports

School

University
/college

District

State

Country

Role
Uniform troop / Association
/ Club

Member

Treasurer

Secretary

Vice
President

President

Ad-hoc
Committee

D. Scholarship History- Please tick ( )

Have you received any scholarship before?

Yes

No

If yes, please provide details:

Sponsor Organization

Value
(RM/Year)

Duration

Are you currently bonded to any scholarship agreement?

Yes

No

E. Course/Programme Details Applied for this Scholarship

Programme of study
(eg: Bachelor In Accountancy)
Name of institution
(eg: Universiti Malaya)
Commencement date/ session
(eg: 1/8/12 / Semester I, 2012/2013)
Duration of study
(eg: 4 years)
Expected graduation date:
(eg: August 2016)
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F. Details of Father / Guardian

Name:
Citizenship:
Date of birth:

New I/C no:

Old I/C no:
Place of birth:

House tel no:

Hand phone no:

Occupation:

Monthly income:

Name & address of employer:

Signature:

G. Details of Mother / Guardian

Name:
Citizenship:
Date of birth:

New I/C no:

Old I/C no:
Place of birth:

House tel no:

Hand phone no:

Occupation:

Monthly income:

Name & address of employer:

Signature:

H. Details of Siblings
No.

Name

Age

Date of
birth

Occupation/
Student

Employer/School

1
2
3
4
5
6
7
8

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Declaration
I hereby declare that all information furnished above are accurate and true to the best of my
belief and Yayasan Bursa Malaysia reserves its rights to terminate/withdraw this application
should any information furnished be discovered as inaccurate and untrue.
Name:

Applicants Signature:

Date:

* To be Completed By Employer of Parent/ Guardian/ Headmaster/

Principal/ Penghulu/ Government Officer within the home vicinity
I hereby verify that all information furnished above are accurate and true to my knowledge.
Name:
Designation:

Signature:

Date:
Official stamp:

Note (*): If any of the parents is an employee of Bursa Malaysia Bhd, this section must be
completed by Head of Department/Section.

FOR OFFICE USE

Date received:

Signature:

Note: Please check the availability and verification of the

following documents and attached them with your submission.
1.

Copy of I/Cs of applicant and parents/guardian

2.

Copy of examination results

3.

Copy of co-curricular activities certificates/ testimonials

4.

Copy of Offer Letter from institution of higher learning (if

available)

5.

Latest copy of parents/guardian salary slip

Please tick ( )

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