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

ARAHAN
INSTRUCTIONS
Taip atau tulis dengan jelas. Gunakan HURUF BESAR.
Please type or write clearly. Please use BLOCK LETTERS.

Gariskan nama keluarga anda.

Type or write your name in full as it appears in your NRIC and underline your surname.
Gambar TERBARU Pemohon

borang permohonan. RECENT Photograph

of Applicant

(Sila rujuk Syarat Permohonan yang dilampirkan).

Tarikh tutup permohonan:

A MAKLUMAT PEMOHON / PARTICULARS OF APPLICANT

Nama pemohon seperti kad pengenalan No. kad pengenalan
Name of applicant as in NRIC NRIC number
Lelaki Perempuan Taraf perkahwinan
Male Female Marital status
Alamat rumah (Tetap) Alamat surat-menyurat
Home address (Permanent) Postal address

Bandar dan Negeri Poskod Bandar dan Negeri Poskod

City and State Postal code City and State Postal code
No. telefon rumah No. telefon bimbit Alamat e-mail
Home telephone no. Handphone no. E-mail address
Tarikh dan tempat lahir Umur Kewarganegaraan Bangsa
Date and place of birth Age Citizenship Race

Kedudukan sekarang pada masa pemohonan Menuntut sepenuh masa Bekerja tetap Bekerja sementara
Present status at time of application Studying full-time Full-time employment Part-time employment

FOR OFFICE USE ONLY

RECEIVED: REF. NO.:

REMARKS:
 B BUTIR-BUTIR KURSUS / COURSE DETAILS
Kursus dipohon (pilihan pertama) / Sedang dituntut
Course applied (first choice) / Attending
Nama institusi Lokasi institusi
Name of institution Location of institution
Jangkamasa kursus Mula kursus Tamat kursus
Duration of course Commencement of course (mm/yyyy) Completion of course (mm/yyyy)

Butir - butir perbelanjaan diperlukan setahun (nyatakan dalam Ringgit Malaysia)

Breakdown of estimated expenses required per annum (in Malaysian Ringgit)
Yuran kursus Yuran lain Tempat tinggal Makanan Perbelanjaan lain Jumlah Bilangan tahun bantuan diperlukan
Tuition fees Other fees Accomodation Food Other expenditure Total No. of years assistance required

0
Sumbangan setahun daripada keluarga / sumber lain. Nyatakan sumber Jumlah bantuan dipohon setahun
Amount per annum which can be obtained from family / other sources. State sources Amount applied for per annum

C MAKLUMAT KELUARGA / INFORMATION ON FAMILY

Nama bapa / penjaga Nama ibu
Father / Guardians name Mothers name
No. kad pengenalan Umur No. kad pengenalan Umur
NRIC number Age NRIC number Age
Alamat Alamat
Address Address

Bandar dan Negeri Poskod Bandar dan Negeri Poskod

City and State Postal code City and State Postal code

No. telefon rumah No. telefon bimbit No. telefon rumah No. telefon bimbit
Home telephone no. Handphone no. Home telephone no. Handphone no.
Pekerjaan Pendapatan kasar sebulan Pekerjaan Pendapatan kasar sebulan
Occupation Gross monthly income Occupation Gross monthly income

Kerja sepenuh masa Kerja separuh masa Perniagaan sendiri Bersara Kerja sepenuh masa Kerja separuh masa Perniagaan sendiri Bersara
Full-time employment Part-time employment Own business Retired Full-time employment Part-time employment Own business Retired

Nama dan alamat majikan / perniagaan sendiri. Jika sudah bersara, nyatakan nama dan Nama dan alamat majikan / perniagaan sendiri. Jika sudah bersara, nyatakan nama dan
alamat majikan / perniagaan sendiri yang terdahulu. alamat majikan / perniagaan sendiri yang terdahulu.
Name and address of employer / own business. If retired, state name and address of Name and address of employer / own business. If retired, state name and address of
previous employer / own business. previous employer / own business.

No. telefon pejabat No. telefon pejabat

Office telephone no. Office telephone no.

Butir - butir SEMUA adik-beradik (kecuali pemohon)

Particulars of ALL brothers and sisters (exclude applicant)
Nama Jantina Umur Taraf Bil. anak Pekerjaan (jika menuntut, nyatakan No. telefon (rumah, Pendapatan
Name Gender Age perkahwinan (jika ada) peringkat pendidikan dan nama bimbit atau pejabat) kasar sebulan
Marital status No. of sekolah / institusi) Telephone no. Gross monthly
children Occupation (If studying, state level (home, handphone income
(if any) of education and name of school / or office)
institution)
 D MAKLUMAT PENDIDIKAN / INFORMATION ON EDUCATION
Butir-butir sekolah pemohon pernah belajar
Details of schools previously attended by applicant
Nama sekolah Bandar dan Negeri Tahun mula Tahun tamat Keputusan yang dicapai
School name City and State Year commenced Year completed Qualifications obtained

E KEPUTUSAN PEPERIKSAAN / EXAMINATION RESULTS

SPM /SPVM / O level atau kelayakan yang setaraf dengannya Tahun STPM / A level / Matrikulasi atau kelayakan yang setaraf dengannya Tahun
SPM / SPVM / O level or equivalent Year STPM / A level / Matriculation or equivalent Year
Mata pelajaran Gred Mata pelajaran Gred
Subject Grade Subject Grade

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 Tahun kedua Tahun ketiga Tahun keempat
First year Second year Third year Fourth year

F PENCAPAIAN KO-KURIKULUM / CO-CURRICULAR ACHIEVEMENTS

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
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 Pinjaman atau biasiswa Nama organisasi / sumber lain Jumlah setahun
Year received Loan or scholarship Name of organisation / other sources 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? Ada Tidak
Have you previously applied to the Kuok Foundation Berhad? Yes No
Tahun permohonan Nombor rujukan, jika ada Jumlah bantuan diterima, jika ada
Year of application Reference number, if any Amount of assistance received, if any
Adakah adik-beradik anda menerima bantuan kewangan dari Yayasan Kuok Berhad? Ada Tidak
Are any of your brothers / sisters assisted by Kuok Foundation Berhad? Yes No
Jika ada, nyatakan nama adik-beradik Tahun, jenis bantuan atau nombor rujukan kami
If yes, state name of brother / sister Year assisted, type of award or our reference number

Adakah adik-beradik anda memohon bantuan kewangan dari Yayasan Kuok Berhad pada tahun ini? Ada Tidak
Have any of your brothers / sisters also applied to Kuok Foundation Berhad this year? Yes No
Jika ada, nyatakan nama adik-beradik Institusi sedang dituntut / dipohon
If yes, state name of brother / sister Institution attending / applied to

H MAKLUMAT PERUJUK / INFORMATION OF REFEREES

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.
Nama (Encik / Cik / Puan) Nama (Encik / Cik / Puan)
Name (Mr / Miss / Mrs / Madam) Name (Mr / Miss / Mrs / Madam)
Alamat Alamat
Address Address

Bandar dan Negeri Poskod Bandar dan Negeri Poskod

City and State Postal code City and State Postal code
No. telefon rumah No. telefon bimbit No. telefon rumah No. telefon bimbit
Home telephone no. Handphone no. Home telephone no. Handphone no.
Pekerjaan No. telefon pejabat Pekerjaan No. telefon pejabat
Occupation Office telephone no. Occupation Office telephone no.
Jumlah tahun mengenali pemohon Pertalian dengan pemohon Jumlah tahun mengenali pemohon Pertalian dengan pemohon
No. of years known Relationship to applicant No. of years known Relationship to applicant

I LAIN-LAIN MAKLUMAT / OTHER INFORMATION

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 Tandatangan pemohon

Date of application 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.
M F 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 -
A+ 3B B+ 7D D : Occ -
1A
A 4B B 8E E : GY -
2A A- 5C C+ 9G G
6C C Siblings GY - 0

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 B- C-
A D
A- C+ R 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 submit the following documents according to the order below. Tick ( ) Yes or No, where appropriate.
If No please explain why under Remarks.
Yes No Remarks
1. University / College / Polytechnic acceptance letter **
2. Parents / Guardians proof of income for the last 2 years **
3. Parents' / Guardians' latest EPF statement, if any **
4. Brothers and sisters proof of income for the last 2 years, if they are working
5. Letters or documents to prove that brothers and sisters are pursuing higher
education in universities / colleges / institutions
6. Applicant's household electricity bill for the last 2 months
7. University / College / Polytechnic results (Actual/Forecast) **
8. STPM / A Level / Matriculation / Foundation (Actual/Forecast) & MUET results **
9. SPM / SPVM / O Level / UEC results (Actual/Forecast) **
10. Identity card and birth certificate of applicant **
11. Birth certificates of all brothers and sisters
12. Parents / Guardians identity cards or death certificate, if deceased
13. School leaving certificates
14. School testimonials (if any)
** Certified true copies are required
 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+ 1. *SPM / SPVM / O Level results Year 2009

Bahasa Inggeris - A-
Pendidikan Moral - B A+ 1 3B B+ 3 7D D
Sejarah - A- 1A
A 1 4B B 2 8E E
Mathematics - B
2A A- 2 5C C+ 2 9G G
Additional Mathematics - C+
Physics - B+ 6C C
Chemistry - B+
Biology - B+
Bahasa Cina - C+
English for Science - A
and Technology

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.