YAYASANKLK

APPLICATIONFORSCHOLARSHIP

Pleasenote: (a) onlyonecopyneedstobefilled.

(b) photocopiesoftherelevantcertificatesincludingUniversity/Collegeletterofaretobe
attachedtothecompletedapplicationform.

(A) PERSONALPARTICULARS

1. NameinFull :
Attach
2. PostalAddress : Recent
Photograph

3. HomeAddress :

4. MobileNumber : 5. IdentityCardNo. :

6. Sex : 7. Married/Single :

8. Race : 9. Religion :

10. DateofBirth : 11. PlaceofBirth :

12. Nationality : 13. EmailAddress :

14. NameofCollege/University :
(Indicatewhichbranchcampusyouarestudyingin )

15. CourseofStudy :
(Statewhetherdegreeordiploma)

16. YearofStudy : *1st/2nd/3rd/4th/5th DurationofCourse : years

17. HaveyoureceivedanyScholarshipAwardsorfinancialassistance?Ifyes,givedetailswithdatesandvalue.

18. Haveyouappliedforanyotherscholarship?Ifyes,givedetails.

19. Detailsofpreviousemployment,ifany,givingnameofemployer,positionheld,etc.:

20. NamesofFather&Mother Address Nationality Age Occupation

(*Deletewhicheverisnotapplicable) Page1
KKS/cyy
21. NamesofBrothers/Sisters Address Age Occupation

(B) SCHOOLS,COLLEGESANDINSTITUTIONSENROLLEDORATTENDED

From To NameofEstablishment TypeofTraining/Education

(C) ACADEMICRECORD(STPM,SPM,PMR,etc.)

Year ExaminationPassed Subjects Grade Subjects Grade

(includingoverallgrade)

Page2

KKS/cyy
(D) EXTRACURRICULARACTIVITIES/POSITIONSOFRESPONSIBILITYHELDINSCHOOL,ETC.

Year DetailsofActivitiesundertaken/Positionsheld

(E) LANGUAGEPROFICIENCY

Written* :

Spoken* :

(*StateifSlight,ModerateorAdvance)

(F) CHARACTERREFERENCES(notrelatives)

Name Address MobileNumber Relationship Period

Known

(1)

(2)

Page3

KKS/cyy
(G) DECLARATIONBY*FATHER/MOTHER/GUARDIAN

1. EstimatedMonthlyIncomeandExpenditure

IncomeperMonth

FromSalary : RM
FromSalaryofSpouse : RM
FromProperty : RM
FromOtherSources : RM

TOTAL : RM

ExpenditureperMonth

OntheFamily : RM
OnChildren'sEducation : RM
OnOtherItems : RM

TOTAL : RM

2. IncomeTaxPaymentsDuringtheLastThreeYears

Year 20 : RM
Year 20 : RM
Year 20 : RM

3. Declarationby*Father/Mother/Guardian
Isolemnlydeclarethattheaboveinformationistrue.

Date :
Signatureof*Father/Mother/Guardian

(*Deletewhicheverisnotapplicable)

Icertifythattheforegoinginformationiscorrect.Iunderstandthatifanyoftheparticularssuppliedby
meprovedtobeuntrue,thescholarshipofferedwillbewithdrawn.

Date:
SignatureofApplicant

Page4
KKS/cyy