For Office use only

Please affix a Ref. No : ____________________________

recent photograph
of applicant 2 completed applications
(non returnable) certified true copy of SPM result
SCHOLARSHIP APPLICATION FORM certified t copy of STPM / Matriculation result
offer letter from university / college
INSTRUCTIONS parents' / guardian's EA form / pay slips
* Please fill in the form by using handwritting c.t.c of applicant IC
* Please use block letters only c.t.c of parent's / guardian's IC
* Attached all certified true copy relevant documents (1 set only) c.t.c of testimonials
* Incomplete applications will be automatically disqualified
* Please submit two copies of application

PART I - PERSONAL DETAILS (STUDENT)

Full Name : ________________________________________________________________________________________________

(As per in NRIC)

NRIC No : - -

Date of birth : _______________ Place of birth : ____________________________ Gender: Male / Female *

Postal Address: Permanent Address:

_________________________________________________ _____________________________________________________
_________________________________________________ _____________________________________________________
_________________________________________________ _____________________________________________________

No. Tel : - No. Tel : -

email address:

PART II - FIELD OF STUDY

CURRENT YEAR OF STUDY :
Course of study : __________________________________
I II III IV
Majoring in : ___________________________________

University/ college : _______________________________________ Please tick at the relevant column and kindly attach
all the certified true copy results if there is any
Duration : ______ year Metric No:______________

Intake Date : - - Expected date of completion / /

d d / m m / y y
Course fees : _______________________
(for the complete course)

* Please attach certified true copy of letter of offer from the university and the official receipt for registeration (if applicable)

page 1 of 6
 PART III - EDUCATION

A. SPM, STPM / MATRICULATION DETAILED RESULTS

Examination School / Instition / University Year Grade/CPGA Main Subjects

SPM 1
2
3
4
5
6
7
8
9
10
11
12
STPM/ 1
Matriculation 2
3
4
5

* Please attach the certfied true copy of the SPM, STPM, Matriculation result, school leaving cert and testimonials

C. OTHER SCHOLARSHIP / LOAN THAT YOU ARE APPLYING

Annual amonut Duration Status (approved /

Scholarship / Loan Organization
(RM) pending approval)

PART IV - EXTRA CURRICULAR ACTIVITIES / SPORTS / COMMUNITY SERVICE

A. Please list down the co-curricular activities you have joined in chronological order

Year Position Held Club / Society / Sports

B. Others (took part in any competetion)

Year Type of Competition and Representing Level Name of School / Institution / university

* Please attach certified true copy of certificate

page 2 of 6
 PART V - FAMILY DETAILS

A. Please provide the family information requested

(Attach with certified true copy of IC, latest EA form or payslip)

Subject Father / Guardian Mother

Full Name

NRIC No.

House Address

Telephone No. : House

Handphone

Date of Birth

Place of Birth

Nationality

Occupation

Company Name and

Address

Office Telephone No.

Salary / Monthly Income

(RM)

Other income

Retired / decease* date

(strike off if irrelevant)

B. Siblings details

Gender School / Institution Scholarship / loan / Single (S) /

Full Name Age M/F Relationship University / Occupation Salary / income Married (M)

C. Total parents incomes RM

page 3 of 6
 PART VI - ASSETS

Please list down the value of assets own by applicant, father, mother, or guardian

Type of assets Applicant Father / Guardian Mother

Land

Property

Shares

Business

Others

PART VII - Referees

Named two referees, the referees must be someone who know you and Foundation may call them to refer if is necessary. Only one family
member is allowed.

Subject Referee I Referee II

Full Name

Postal Address

Telephone No.

Nationality

Occupation

Monthly Gross Income

Employer Name and Address

Office Tel. & Fax Number Tel: Tel:

Fax: Fax:

page 4 of 6
 PART VIII - ESSAY

Write an essay in approximately 300 words (use a separate sheet if is necessary) on the following:
1) self & family
2) Ambition & Career
3) Why do you need a scholarship?
4) How will the S P Setia Foundation scholarship assist you in achieving your ambition?
5) What will you do if you are not offered this scholarship?

page 5 of 6
 PART IX - CHECK LIST

2 COPIES COMPLETED APPLICATION FORMS

RECENT PHOTOGRAPH ATTACHED

CERTIFIED TRUE COPY OF IDENTITY CARD

CERTIFIED TRUE COPY OF PARENTS' IDENTITY CARD

CERTIFIED TRUE COPY OF SPM / STPM / MATRICULATION RESULTS, TESTIMONIALS AND OTHER CERTIFICATES.

CERTIFIED TRUE COPY OF UNIVERSITY/ COLLEGE OFFER LETTER

CERTIFIED TRUE COPY OF PARENTS' / GUARDIAN'S RECENT EA FORM OR 3 MONTHS MOST RECENT PAY SLIPS

PART X - DECLARATION BY APPLICANT

I certify that the information I have given on this application is complete and correct . I understand that falsification of my application or
records is grounds for immediate cancellation of this scholarship.

Date : ____________________________ ________________________________

(Signature of Applicant)

SEND APPLICATION TO:

Completed application with ceritified true copy document need to send to the following address or your Student Affairs Dept.
Kindly indicate "S P Setia Foundation Scholarship Award" on the top left hand corner of the envelope.

THE SECRETARY
S P SETIA FOUNDATION
Setia Corporate Tower
5A, Jalan Setia Nusantara U13/17
Setia Alam, Seksyen U13
40170 Shah Alam, Selangor

Reminder: Incomplete application and late submission will not be entertained.

Closing date: 30th June 2010

page 6 of 6