Preliminary Application Form 2017 Recent Photo

Borang Permohonan 2017

Gambar Terbaru 

All forms must be HANDWRITTEN clearly in BLACK or BLUE ink pen and every question must be answered.
Setiap borang hendaklah ditulis dengan jelas menggunakan dakwat HITAM atau BIRU sahaja. Sila jawab semua soalan dengan lengkap.

CHECKLIST‐ SENARAI SEMAK  
Check that you have filled ALL the information on this form and include:
Semak semula SETIAP maklumat yang telah diisi dan sertakan lampiran yang berikut:

RM30 cheque/postal order/money order No._________ made payable to 'Yayasan AFS Antarabudaya Malaysia' (Compulsory)
RM30 dalam bentuk cek/wang pos/kiriman wang No. __________ atas nama ‘Yayasan AFS Antarabudaya Malaysia’ (Wajib)

Your past 2 years’ school results (Compulsory)

Keputusan peperiksaan terkini bagi 2 tahun lalu (Wajib)

A photocopy of your IC (both side) (Compulsory)

Satu salinan kad pengenalan (kedua-dua belah) (Wajib)

A recent passport photograph of yourself (Compulsory)

Gambar ukuran passport yang terbaru (Wajib)

PERSONAL INFORMATION – MAKLUMAT PERIBADI  
Full name (as in IC) – Nama Penuh (seperti dalam K/P) Birth date – Tarikh Lahir Gender- Jantina
(dd/mm/yy)
Male
(Lelaki)
Home Phone Number – No. Telefon Rumah: Mobile Number – No. Telefon Bimbit:
Female
(Perempuan)

Home Address - Alamat Rumah: Do you have a disability?

Adakah anda mengalami sebarang kecacatan fizikal?

Yes/Ya
No/Tidak

If Yes, please give details: (Jika Ya, sila nyatakan:)

Email Address - Alamat Emel:

Note: Please submit only photocopy of original documents (IC, school results, and certificates). AFS Malaysia will not be responsible in
sending back original copies.
Peringatan: Sila hantarkan salinan dokumen asal sahaja (K/P, Keputusan peperiksaan terkini, dan sijil-sijil). AFS Malaysia tidak akan
bertanggungjawab dalam memulangkan dokumen asal anda.

To find out which country/destination is the right fit for you, please refer to page 7 and 8.
Bagi destinasi program AFS yang sesuai dengan anda, sila rujuk muka surat 7 dan 8.
If you require assistance with your preliminary application, or have any questions about our programs, please email our ‘Sending Team’ at info-
mas@afs.org or call us at 03 7887 6866. Please note that our office hour is Monday – Friday (9am-5pm).
Jika anda memerlukan bantuan berkenaan permohonan anda, atau memerlukan maklumat lanjut tentang program kami, sila emel ‘Sending
Team’ kami di info-mas@afs.org atau hubungi kami di talian 03 7887 6866. Pejabat kami beroperasi pada hari Isnin hingga Jumaat (9 Pagi- 5
Petang).

Page 1 of 10
PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA
SCHOOL INFORMATION‐ MAKLUMAT SEKOLAH  
Name of School- Nama Sekolah:

School Address- Alamat Sekolah:

Telephone Number- No. Telefon: Fax Number- No. Fax:

I am in Form (kindly provide class name): Type of School (Please tick)

Saya di tingkatan (sila nyatakan nama kelas): Jenis Sekolah (Sila tandakan)

Residential / Asrama Penuh

Religious / Sekolah Agama
Private School / Sekolah Swasta
Post held in school (if any):
Jawatan disandang di sekolah (jika ada): Special Education / Pendidikan Khas
Daily School / Sekolah Harian:
o Sekolah Menengah Kebangsaan
o Sekolah Jenis Kebangsaan Cina
o Sekolah Jenis Kebangsaan India
o Lain-lain: __________________

PARENTS/GURDIAN(S) INFORMATION‐ MAKLUMAT IBU BAPA/ PENJAGA 

What is your family structure? / Apakah status ibu bapa anda?

Parents are: / Ibu bapa saya:
married separated single parent divorced
berkahwin tinggal berasingan Ibu bapa tunggal berpisah

Information about the people with whom I live / Maklumat ibu/bapa yang saya tinggal bersama:

I live with: both my father and my mother my mother my father stepmother stepfather
Saya tinggal bersama: Kedua ibu bapa saya ibu sahaja bapa sahaja ibu tiri bapa tiri

my guardian(s), indicate your relationship to your guardian(s), ______________

penjaga, hubungan saya dengan penjaga ialah _______________

Father/Guardian: Divorced Deceased Separated

Bapa/Penjaga: Bercerai Meninggal Berpisah
Father/Stepfather/Guardian Name- Nama Bapa/Bapa Tiri/Penjaga:

Employer- Majikan: Occupation-Pekerjaan:

Office Number- No. Pejabat: Mobile Number-No. Telefon Bimbit: Email Address- Alamat Emel:

Mother/Guardian: Divorced Deceased Separated

Ibu/Penjaga: Bercerai Meninggal Berpisah
Mother/Stepmother/Guardian Name- Nama Ibu/Ibu Tiri/Penjaga:

Employer- Majikan: Occupation-Pekerjaan:

Office Number- No. Pejabat: Mobile Number-No. Telefon Bimbit: Email Address- Alamat Emel:

Page 2 of 10
PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA
 SIBLING(S) INFORMATION‐ MAKLUMAT ADIK‐BERADIK 

Name-Nama Age-Umur Gender-Jantina School/Institution-Sekolah/Institusi

EMERGENCY CONTACT‐MAKLUMAT KECEMASAN  

If your parents/guardian cannot be reached, please indicate someone in your community whom we can contact:
Jika ibu bapa/penjaga tidak dapat dihubungi,sila nyatakan maklumat individu yang boleh dihubungi:

Full Name-Nama Penuh: Relationship-Hubungan:

Office Phone-No.Telefon Pejabat: Home Phone- No.Telephone Rumah: Mobile Number- No. Telefon Bimbit:

LANGUAGE BACKGROUND 
What are the primary languages spoken in your home? / Apakah bahasa pertuturan anda di rumah?

Malay / Bahasa Melayu English / Bahasa Inggeris

Mandarin / Bahasa Mandarin Others / Lain-lain: _______________

Tamil / Bahasa Tamil

What other languages do you know? Please indicate your speaking ability in each language. / Apakah bahasa pertuturan lain yang anda tahu?
Sila nyatakan kemahiran bertutur anda.

Language/ Year of studies/ Speaking abilities/ Study at/

Bahasa: Tahun Pengajian: Kemahiran Bertutur: Belajar di:
    Poor  Fair  Good  Excellent  School  Extra Course 
Lemah  Sederhana  Bagus  Amat Bagus  Sekolah  Kelas Tambahan 
    Poor  Fair  Good  Excellent  School  Extra Course 
Lemah  Sederhana  Bagus  Amat Bagus  Sekolah  Kelas Tambahan 
    Poor  Fair  Good  Excellent  School  Extra Course 
Lemah  Sederhana  Bagus  Amat Bagus  Sekolah  Kelas Tambahan 
    Poor  Fair  Good  Excellent  School  Extra Course 
Lemah  Sederhana Bagus Amat Bagus Sekolah  Kelas Tambahan

Page 3 of 10
PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA
 PERSONAL STATEMENT – PENGENALAN DIRI  

1. Tell us about yourself: Introduce yourself, your personality, your relationship with your family and friends, your responsibilities at
home/school, list your favourites, interests or hobbies etc./ Perkenalkan diri anda, personaliti anda, hubungan anda dengan keluarga dan
rakan-rakan, tanggungjawab di rumah / sekolah, senaraikan kegemaran, minat atau hobi anda.
2. Tell us about your expectation (before,during & after) the exchange program / Sila nyatakan harapan anda (sebelum, semasa & selepas)
program pertukaran ini.
3. Tell us about your participation in school and community activities / Senaraikan penyertaan anda di sekolah dan aktiviti-aktiviti
kemasyarakatan
4. Tell us about your goals/plans which are important to you; and why you think you should be chosen for the AFS Program? / Sila nyatakan
matlamat / perancangan yang penting kepada anda; dan mengapa anda layak dipilih untuk Program AFS?

** Your personal statement should be between 100 -250 words ONLY / Kenyataan diri anda haruslah di antara 100-250 patah perkataan
SAHAJA

Page 4 of 10
PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA
 OTHER INFORMATION ‐ MAKLUMAT LAIN  

How did you hear about AFS? - Bagaimanakah anda tahu mengenai AFS?

Online/Atas Talian School/Sekolah Road Show/ Promosi Bergerak

Friends / Rakan Newspaper / Surat Khabar Others / Lain-Lain

__________________

Have any of your family members participated on an AFS program? Adakah sesiapa dari ahli keluarga anda yang pernah menyertai
program AFS?

No/Tidak Yes, please specify student’s name, host country and which year? Ya.Sila nyatakan nama
Pelajar, negara dan tahun penyertaan.

Are you or any of your family members involved in AFS? Adakah anda atau sesiapa dari ahli keluarga anda terlibat di dalam AFS?
No/ Tidak Yes. If yes,how?/ Ya.Jika ya, bagaimana?

Do you have any volunteer experience? If yes, please list your volunteer activities.
Sila nyatakan disini sekiranya anda mempunyai sebarang pengalaman dalam aktiviti sukarelawan.

1. ______________________________________________________________ Year/Tahun: _________________

2. ______________________________________________________________ Year/Tahun: _________________

3. ______________________________________________________________ Year/Tahun: _________________

4. ______________________________________________________________ Year/Tahun: _________________

5. ______________________________________________________________ Year/Tahun: _________________

Are you willing to host an AFS participant?

Adakah anda sudi menjadi keluarga angkat kepada peserta AFS?

Yes / Ya
No / Tidak

Have you ever participated in any other exchange programs, travelled abroad or lived in another country?
(Please provide details; exchange program name, travel duration and country name)
E.g.: UCC Summer Course in England in 2014 for two weeks (15 -29 November, 2014)

Adakah anda pernah menyertai mana-mana program pertukaran, melancong atau menetap di luar negara?
(Sila nyatakan nama program, tempoh dan nama negara)
Cth: UCC Summer Course di England pada tahun 2014 selama 2 minggu (15 -29 November, 2014)

No/ Tidak Yes. If yes, where and when, for what purpose? / Ya. Jika ya, dimana dan bila? Tujuan?

Page 5 of 10
PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA
 INTERESTS AND ACTIVITIES 
Please (√) select 5 to 10 activities of your interests below.
Sila (√) pilih 5 hingga 10 aktiviti kesukaan anda di bawah.

Individual Sports:

Hiking Horseback Riding Cycling Sailing/Boating Camping Canoeing Fishing

Mendaki Menunggang Kuda Berbasikal Berlayar Berkhemah Berkayak Memancing

Yoga Skateboarding Aerobics Hunting Jogging Martial Arts

Yoga Bermain Papan Luncur Aerobik Memburu Joging Seni Mempertahankan Diri

Organized Sports:

Hockey Baseball Basketball Gymnastic Softball Wrestling Tennis

Hoki Baseball Bola jaring Gimnastik Softball Gusti Tenis

Soccer Track & Field Diving/Swimming Volleyball Golf Cross-country Running

Bola Sepak Aktiviti Padang Menyelam/Berenang Bola Tampar Golf Merentas Desa

Art, Dance and Theatre:

Ballet Drawing/painting Debate Photography Videography

Balet Melukis Debat Fotografi Videografi
Theatre/Drama Movie/Cinema Cultural Activities Crafts Dance
Teater/Drama Menonton wayang Aktiviti Kebudayaan Kraf Tarian

Music:

Musical Instrument Singing Orchestra Concert Listening to Music Brass Band

Alat Musik Menyanyi Orkestra Konsert Mendengar Musik Pancaragam

Individual:

Board Games Social Dancing Collecting Gardening Journalism Travel

Mainan Tarian Social Mengumpul Berkebun Penulisan Melancong

Cooking Reading Watching Television Computer Games

Memasak Membaca Menonton Television Permainan Komputer

Community Activities:

Religion Services School Activities Scouts/Guides Volunteer Activity

Khidmat Keagamaan Aktiviti Sekolah Pengakap Aktiviti Sukarela

DECLARATION‐ AKU JANJI  

I HAVE DISCUSSED MY APPLICATION WITH MY FAMILY AND WISH TO APPLY FOR PARTICIPATION IN AN AFS PROGRAM
SAYA TELAH BERBINCANG DENGAN KELUARGA SAYA MENGENAI PERMOHONAN INI DAN INGIN MEMOHON UNTUK
MENYERTAI PROGRAM AFS

Applicant’s Signature / Tandatangan Pemohon Parent/Guardian’s Signature / Tandatangan Ibu/Bapa/Penjaga

Date/Tarikh: Date/Tarikh:

Page 6 of 10
PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA
 SOUTHERN HEMISPHERE (SH) CYCLE 2017/2018 (Jan - Jun Depart)
YEAR PROGRAM (8 MONTHS OR MORE)
FORM
DESTINATION DEPART RETURN FEE (RM)
(YR 2017)
Argentina Feb ‘18 Jan ‘19 40,000 5
Brazil Feb ‘18 Jan ‘19 36,000 5
Chile Feb ‘18 Jan ‘19 33,000 5
China Feb ‘18 Dec ‘18 32,000 5
Denmark Feb ‘18 Jan ‘19 35,000 5
Germany Feb ‘18 Jan ‘19 40,000 5
Japan Mar ‘18 Feb ‘19 33,000 5
New Zealand Jan ‘18 Dec ‘18 58,000 5
Switzerland Feb ‘18 Jan ‘19 46,000 5
SEMESTER PROGRAM (4 – 8 MONTHS)
FORM
DESTINATION DEPART RETURN FEE (RM)
(YR 2017)
Australia Feb ‘18 July ‘18 35,000 5
Austria Jan ‘18 July ‘18 26,000 5
Brazil Feb ‘18 July ‘18 29,000 5
France Jan ‘18 July ‘18 28,000 5
Hungary Jan ‘18 July ‘18 24,000 5
Italy Jan ‘18 July ‘18 26,000 5
Japan Mac ‘18 August ‘18 28,000 5
Poland Feb ‘18 July ‘18 26,000 5
Russia Jan ‘18 June ‘18 24,000 5
Spain Jan ‘18 June ‘18 29,000 5
USA (KL-YES) Jan ‘18 June ‘18 (Scholarship) 5

INTENSIVE PROGRAM (UP TO 4 WEEKS)

FORM
DESTINATION DEPART RETURN FEE (RM)
(YR 2017)
Denmark (Ranum Efterskole) Jan ‘18 Feb ‘18 23,000 3,5

NORTHERN HEMISPHERE (NH) CYCLE 2018/2019 (July – Dec Depart)

YEAR PROGRAM (8 MONTHS OR MORE)
FORM
DESTINATION DEPART RETURN FEE (RM)
(YR 2017)
Austria Sept ‘18 June ‘19 32,000 5
Belgium Flanders Aug ‘18 July ‘19 36,000 5
Bosnia Herzegovina Sept ‘18 July ‘19 36,000 5
Brazil August ‘18 June ‘19 36,000 5
China August ‘18 June ‘19 32,000 5
France Sept ‘18 July ‘19 38,000 5
Hungary August ‘18 July ‘19 34,000 5
INTENSIVE PROGRAM (4-11 WEEKS)
Finland July ‘18 Aug ‘18 20,000 3,5
Japan (School Based) Oct ‘17 Nov ‘17 18,000 4
Japan (Language) Dec ‘17 Dec ‘17 22,000 3,4,5
Turkey Dec ‘17 Feb ‘18 19,000 3,4,5
Italy Dec ‘17 Feb ‘18 19,000 3,4,5
China Dec ‘17 Feb ‘18 19,000 3,4,5
Page 7 of 10
PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA

 
 France * Dec ‘17 Feb ‘18 23,000 3,4,5
Germany (Green Academy) July ‘18 August ‘18 23,000 3,5
Italy (Arts Program) June ‘18 July ‘18 22,000 3,5
Spain (Summer Academy) June ‘18 July ‘18 25,000 3,5

*Minimum 2 years of studying French Language is required

*Minimum 2 tahun pengajian Bahasa Perancis adalah diperlukan

EDUCATORS PROGRAM
WHO CAN APPLY
DESTINATION DEPART RETURN FEE (RM)
(YR 2017)
School Teachers/
New Zealand (2 Weeks) May/Nov 18 - 14,000
Educators

Scholarships

As part of AFS Malaysia‘s commitment to help your dream come true, we offer various scholarships that you could be eligible for!
Sebahagian dari komitmen kami di Yayasan AFS Antarabudaya Malaysia adalah untuk membantu menjadikan impian anda kenyataan
dengan menawarkan pelbagai biasiswa.

Scholarships available:
Biasiswa-Biasiswa yang ditawarkan:

Yayasan AFS Antarabudaya Malaysia (YABM)

This is a partial scholarship open to all students who wish to go on the Year Program.
Preferences will be given to those applying for non-English speaking countries. Terms and
conditions apply.

Kennedy-Lugar Youth Exchange and Study (KL-YES)

The Kennedy-Lugar Youth Exchange and Study (YES) Program was established by the US
Congress in October, 2002 in response to the events of September 11, 2001. The program is
funded through the U.S. Department of State and sponsored by the Bureau of Educational &
Cultural Affairs (ECA) to provide scholarships for high school students (17 years) from
countries with significant Muslim populations to spend up to one academic year in the US. A full
scholarship offered to all students aged 17 years / Form 5 who wish to go to USA on the
Semester Program.

Carl Zeiss Scholarship

A partial scholarship will be offered to children's employee of Carl Zeiss. The scholars can
choose 35 destinations offered by the scholarship. Some of AFS destinations are: Argentina,
Belgium, Chile, Hong Kong, France, Finland and more. Further information can be obtained
through Carl Zeiss Corporation.

AFS PROGRAMS PREFERENCE ‐ PILIHAN PROGRAM AFS 

My preferred countries are (kindly refer to page 7 and 8) - Negara-negara pilihan saya adalah (sila rujuk muka surat 7 dan 8)
1) 2) 3)

We cannot guarantee your first choice but we will do our best! / Kami tidak memberi sebarang jaminan anda akan mendapat pilihan pertama anda.

Please state your preferred choice of AFS Programs: Departing in:

Sila nyatakan program AFS pilihan anda Berlepas pada:

Year Program (8 months or more) Dec/Jan/Feb/Mac

Program Setahun (8 bulan atau lebih) Dis/Jan/Feb/Mac

Semester Program (4-8 months) Jun/Jul/Aug/Sept

Program Semester (4-8 bulan) Jun/Jul/Ogos/Sep

Intensive Program (4-11 weeks)

Program Intensif (4-11 minggu)

Page 8 of 10
PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA

 
SCHOLARSHIP APPLICATION – PERMOHONAN BIASISWA  
For the list of scholarships available, please refer to the list of scholarship on page 8.
Sila rujuk muka surat 8 bagi senarai biasiswa yang boleh dipohon.

If you wish to apply for an AFS or YES Scholarship, please complete the scholarship section below.
Jika anda ingin memohon untuk biasiswa AFS atau YES, sila lengkapkan bahagian biasiswa di bawah.

I am applying for the following scholarship(s) for which I am eligible for:

Saya layak untuk memohon biasiswa berikut:

Name of Scholarship(s):
Nama Biasiswa:

Family Annual Income (Please tick):

Pendapatan tahunan keluarga (Sila tandakan):

Up to RM50,000 / Sehingga RM50,000 RM51,000-RM100,000 RM101,000-RM150,000

RM151,000-RM200,000 RM201,000 and above/

Lebih dari RM201,000

Number of dependents /Jumlah tanggungan: ________________________________________________________________________

I deserve a scholarship because… (Not more than 30 words) / Saya layak untuk menerima biasiswa kerana… (tidak melebihi 30 perkataan)
 
 
 
 
 
 
 
 
 
 

Please note that this scholarship application does not automatically guarantee you an AFS Scholarship. Your application will be
reviewed by the AFS Selection Committee to determine your eligibility. However, you may still participate as a fee-paying candidate if
you are unable to secure a scholarship.
We trust that your information in this application is valid, failing which your application will be disqualified.

Sila maklum bahawa permohonan biasiswa ini tidak menjamin biayaan Biasiswa AFS secara otomatik. Permohonan anda akan ditapis
oleh Jawatankuasa Pemilihan AFS bagi menentukan calon yang layak. Bagaimanapun, anda masih boleh menyertai program ini sebagai
calon berbayar, sekiranya anda tidak terpilih untuk biasiwsa ini.
Sekiranya didapati sebarang maklumat yang diberi tidak benar, permohonan anda akan dibatalkan.

Page 9 of 10
PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA
SUBMISSION POLICY /POLISI PENGHANTARAN
Send this completed application form on or before 30 April 2017 to:
Hantarkan borang permohonan yang lengkap sebelum atau pada 30 April 2017 kepada:
 
 
  SENDING DEPARTMENT
  AFS MALAYSIA
A-10-2, Block A, Plaza Glomac,
  Jalan SS 7/19, Kelana Jaya
47301 Petaling Jaya,
Selangor Darul Ehsan
Malaysia

Cheque/Money/Postal Order payable to:

Yayasan AFS Antarabudaya Malaysia

APPLICATION DEADLINE/ TARIKH TUTUP:

30 APRIL 2017

IMPORTANT NOTES:

1. Please note that AFS Malaysia reserves the right to change the program fee and details without prior notice.
Programs Fee is inclusive of GST charges.
AFS Malaysia berhak menukar jumlah yuran serta syarat dan terma tanpa sebarang notis. Yuran program termasuk GST.

2. AFS Malaysia also reserves the right not to proceed with the program if it is deemed not viable or is cancelled by
the host country.
AFS Malaysia juga berhak untuk tidak meneruskan program jika didapati ianya tidak sesuai ataupun dibatalkan oleh
negara yang menawarkan program tersebut.

3. The RM 30.00 application fee is not refundable.

Yuran permohonan sebanyak RM 30.00 tidak akan dikembalikan.

4. Incomplete applications will be rejected.

Permohonan yang tidak lengkap tidak akan diproses.

5. Short listed candidates will be called for an interview in May/June 2017 (interview may be held during school
holidays). Request to change date and venue will not be entertained.
Pelajar yang disenarai pendek akan dipanggil untuk menghadiri temuduga pada bulan Mei/Jun 2017 (temuduga
berkemungkinan diadakan semasa cuti sekolah). Permohonan untuk menukar tarikh atau tempat temuduga tidak akan
dilayan.

6. All applications must be submitted to AFS Malaysia office as printed copies, applications submitted via online
(via email) will not be considered.
Semua salinan permohonan perlu dihantar ke pejabat AFS Malaysia, penghantaran melalui atas talian (melalui emel)
tidak akan dilayan.

7. Applicants must submit only photocopy of original documents. AFS Malaysia will not be responsible in sending
back original copies.
Permohonan mestilah dihantar dengan salinan dokumen asal sahaja. AFS Malaysia tidak akan bertanggungjawab dalam
memulangkan dokumen asal anda.

8. For any inquiries regarding AFS Program application, please email to info-mas@afs.org with the Subject
Heading: AFS Application 2017-18 Inquiry.
Bagi sebarang pertanyaan berkenaan permohonan Program AFS, sila emel kepada: info-mas@afs.org dengan Tajuk
Subjek: Pertanyaan Permohonan AFS 2017 - 18.

9. Students going on AFS programs need to comply with host country’s rules and regulations.
Pelajar-pelajar yang mengikuti program AFS adalah tertakluk kepada terma dan syarat yang ditetapkan oleh negara
penempatan.

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PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA