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No:

THE SELANGOR AND KUALA LUMPUR

TEO CHEW ASSOCIATION
35-A, Jalan Ampang, 50450 Kuala Lumpur.
Tel : 03-2078 2492, 2031 3361
Fax: 03-2070 1882

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Application Form for Pre-U, Diploma & University Scholarship

Name of Student: Chinese

Apply for:

English

Pre-U Scholarship

Diploma Scholarship

University Scholarship

(A) PARTICULARS OF UNIVERSITY/ COLLEGE/ SCHOOL

1.

Name of University, College or school of which Studying Admission obtained Applied.

2. Address of University, College or School

3. State course selected:

4.
Duration of the course:

()
(Month)

5. Length of the couse :

6. Next Academic year:
1st.
2nd.
3rd.
4th.
year

()
(Year )
Year(s)

to

()
(Month)

()
(Year )

(B) PERSONAL PARTICULARS

1.
2.
3.

4.
5.

Chinese
Name of Applicant : English

Membership No.(If Member)

If apply by student, please state (If Member):

Father's Name:

Mother's Name:

Date & Place Of Birth:

6.
Sex:
Native Province:

Date of Entrance:

Membership No.:

Membership No.:

7.
NRIC No.:

8.

Office Address:

9.

Home Address:

10.

Tel
(H/P) :
(O) :
(RES) :

At present, whether in receipt of any scholarship, bursary/ Study Loan from other
organisation (give details, if any).

11.

12.

Prior to this application, state whether any other scholarship, bursary/ Study Loan
have been sought (give details, if any).
(Note: Subsequent to this application, other similar applications made by the applicants to any
organization, Photostat copies of those applications should be forwarded to the Association
for ref.)

13.

Whether other members of the family apply for the scholarship from our association?
(give details, if any)
Name:

Diploma Scholarship (Recipient / Currently apply)

University Scholarship(Recipient / Currently apply)

Pre-U Scholarship(Recipient / Currently apply)

(C) ACADEMIC PARTICULARS AND RESULTS

C1. Academic records

Year

Name & Address of School

Standard Passed
S.P.M.

S.T.P.M

( II )

COLLEGE

III
IV
V

C2. Academic results

(a)

Examination takenSPM

Year:

Subject

Grade
SPM

Subject

VI

( II )

( VII )

III

VIII

IV

IX

Grade
SPM

(b)

Examination takenSTPM

Year:

Subject

Grade

STPM

Subject

VI

( II )

( VII )

III

VIII

IV

IX

Grade

STPM

STPM

Aggregate:

(c)

Examination takenUNIVERSITY / DIPLOMA

Year:

Subject

Grade

Subject

VI

( II )

( VII )

III

VIII

IV

IX

Grade

(D) DETAILS OF ACTIVITIES

1.

Whether participating or holding office in school activities (give details, if any)

2.

Whether representing school or other sports organisation participating in sports

activities (give details, if any)

3.

Whether pursuing any study at present (give details, if any)

(E) TESTIMONIAL FROM SCHOOL CONCERNED

Grade
(F) DETAILS OF FAMILY INCOME
FORM J / Please attach Income Tax Form J

1.
No

Relationship

All Name of Member

Age

Marriage Status

Occupation

Monthly Income

1.
2.
3.
4.
5.

2.

Total

In addition to the above, whether in receipt of any other income (give details, if any)

(G)
GIVE NAMES, ADDRESS AND OCCUPATION OF TWO REFEREES:
1.
Name(Chinese):

Occupation:

Address:

Hand phone:

(Off):

(English)

Date of Birth:

Tel(Res):

I
, as a referee, hereby declare that all particulars stated above
are true and agree to provide particulars of the applicant when requested by the Association

Signature of Referee:

Date:
2.
Name(Chinese):

Occupation

Address:

Hand phone

Nric No.:

English

Date of Birth:

Tel(Res):

I
, as a referee, hereby declare that all particulars
stated above are true and agree to provide particulars of the applicant when
requested by the Association

Signature of Referee:

Date:

Nric No.:

I declare that all particulars stated above are true and I undertake to abide by the decision
of The Selangor and Kuala Lumpur Teo Chew Association Scholarship Fund Committee.

Signature of Applicant

Date:

Please attach certified True Copy Of (Please arrange in the following order)
1. Student Card
2. School Receipt
3. Letter of Offer
4. Examination Result
5. Testimonial From School
6.
Parents latest income tax return, if no income tax forms, submit
proof of payroll.
7.
Student's I.C

8. Student's Birth Certificate

Applicants are requested to submit a certified true copy of admission to University

College / School immediately to the Association when notified by the Authority concerned