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: [email protected] Website: www.kuokfoundation.com
Borang permohonan untuk bantuan kewangan pelajaran
Application form for educational assistance
FOR OFFICE USE ONLY
RECEIVED: REF. NO.:
REMARKS:
A
MAKLUMAT PEMOHON / PARTICULARS OF APPLICANT
Gambar TERBARU Pemohon
RECENT Photograph of Applicant
ARAHAN
INSTRUCTIONS
Taip atau tulis dengan jelas. Gunakan HURUF BESAR.
Please type or write clearly. Please use BLOCK LETTERS.
(Sila rujuk Syarat Permohonan yang dilampirkan).
Gariskan nama keluarga anda.
Type or write your name in full as it appears in your NRIC and underline your surname.
borang permohonan.
Tarikh tutup permohonan:
Nama pemohon seperti kad pengenalan
Name of applicant as in NRIC No. kad pengenalanNRIC number
Taraf perkahwinan
Marital status
Alamat rumah (Tetap)
Home address (Permanent)
No. telefon rumah
Home telephone no. No. telefon bimbitHandphone no. Alamat e-mailE-mail address
Alamat surat-menyurat
Postal address
Tarikh dan tempat lahir
Date and place of birth UmurAge KewarganegaraanCitizenship BangsaRace
Menuntut sepenuh masa
Studying full-time Bekerja tetapFull-time employment Bekerja sementaraPart-time employment
Kedudukan sekarang pada masa pemohonan
Present status at time of application
Poskod
Postal code
Poskod
Postal code Bandar dan NegeriCity and State
Bandar dan Negeri
City and State
Lelaki
B
BUTIR-BUTIR KURSUS / COURSE DETAILS
Yuran kursus
Tuition fees Other feesYuran lain Tempat tinggalAccomodation MakananFood Other expenditurePerbelanjaan lain JumlahTotal Bilangan tahun bantuan diperlukanNo. of years assistance required
Sumbangan setahun daripada keluarga / sumber lain. Nyatakan sumber
Amount per annum which can be obtained from family / other sources. State sources Jumlah bantuan dipohon setahunAmount applied for per annum Kursus dipohon (pilihan pertama) / Sedang dituntut
Course applied (first choice) / Attending Nama institusi
Name of institution Lokasi institusiLocation of institution
Jangkamasa kursus
Duration of course Mula kursusCommencement of course (mm/yyyy) Tamat kursusCompletion of course (mm/yyyy)
Butir - butir perbelanjaan diperlukan setahun (nyatakan dalam Ringgit Malaysia) Breakdown of estimated expenses required per annum (in Malaysian Ringgit)
C
MAKLUMAT KELUARGA / INFORMATION ON FAMILY
Butir - butir SEMUA adik-beradik (kecuali pemohon) Particulars of ALL brothers and sisters (exclude applicant)
Nama
Name JantinaGender UmurAge Taraf perkahwinan
Marital status Bil. anak (jika ada) No. of children (if any)
Pekerjaan (jika menuntut, nyatakan peringkat pendidikan dan nama sekolah / institusi)
Occupation (If studying, state level of education and name of school / institution)
No. telefon (rumah, bimbit atau pejabat) Telephone no. (home, handphone or office) Pendapatan kasar sebulan Gross monthly income Kerja sepenuh masa
Full-time employment Kerja separuh masaPart-time employment Perniagaan sendiriOwn business BersaraRetired
Nama bapa / penjaga
Father / Guardian’s name Nama ibu Mother’s name
No. kad pengenalan
NRIC number UmurAge No. kad pengenalanNRIC number UmurAge
Alamat Address
No. telefon rumah
Home telephone no. No. telefon bimbitHandphone no. Poskod Postal code Bandar dan Negeri
City and State
Kerja sepenuh masa
Full-time employment Kerja separuh masaPart-time employment Perniagaan sendiriOwn business BersaraRetired
Nama dan alamat majikan / perniagaan sendiri. Jika sudah bersara, nyatakan nama dan alamat majikan / perniagaan sendiri yang terdahulu.
Name and address of employer / own business. If retired, state name and address of previous employer / own business.
Nama dan alamat majikan / perniagaan sendiri. Jika sudah bersara, nyatakan nama dan alamat majikan / perniagaan sendiri yang terdahulu.
Name and address of employer / own business. If retired, state name and address of previous employer / own business.
Pekerjaan
Occupation Pendapatan kasar sebulanGross monthly income
Alamat Address
Poskod Postal code Bandar dan Negeri
City and State No. telefon rumah
Home telephone no. No. telefon bimbitHandphone no. Pekerjaan
Occupation Pendapatan kasar sebulanGross monthly income
No. telefon pejabat
D
MAKLUMAT PENDIDIKAN / INFORMATION ON EDUCATION
E
KEPUTUSAN PEPERIKSAAN / EXAMINATION RESULTS
F
PENCAPAIAN KO-KURIKULUM / CO-CURRICULAR ACHIEVEMENTS
Butir-butir sekolah pemohon pernah belajar Details of schools previously attended by applicant Nama sekolah
School name Bandar dan NegeriCity and State Tahun mulaYear commenced Tahun tamatYear completed Keputusan yang dicapaiQualifications obtained
Mata pelajaran Subject SPM /SPVM / ‘O’ level atau kelayakan yang setaraf dengannya
SPM / SPVM / ‘O’ level or equivalent Mata pelajaran
Subject GredGrade
Tahun
Year STPM / ‘A’ level / Matrikulasi atau kelayakan yang setaraf dengannyaSTPM / ‘A’ level / Matriculation or equivalent Gred Grade Tahun Year
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
First year Tahun keduaSecond year Tahun ketigaThird year Tahun keempatFourth year
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
G
BANTUAN KEWANGAN / FINANCIAL ASSISTANCE
I
LAIN-LAIN MAKLUMAT / OTHER INFORMATION
H
MAKLUMAT PERUJUK / INFORMATION OF REFEREES
Ada Yes TidakNo Ada Yes TidakNo Ada Yes TidakNo
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
Year received Pinjaman atau biasiswaLoan or scholarship Nama organisasi / sumber lainName of organisation / other sources Jumlah setahunAmount 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? Have you previously applied to the Kuok Foundation Berhad?
Tahun permohonan
Year of application Nombor rujukan, jika adaReference number, if any Jumlah bantuan diterima, jika adaAmount of assistance received, if any Adakah adik-beradik anda menerima bantuan kewangan dari Yayasan Kuok Berhad?
Are any of your brothers / sisters assisted by Kuok Foundation Berhad? Jika ada, nyatakan nama adik-beradik
If yes, state name of brother / sister Tahun, jenis bantuan atau nombor rujukan kamiYear assisted, type of award or our reference number Adakah adik-beradik anda memohon bantuan kewangan dari Yayasan Kuok Berhad pada tahun ini?
Have any of your brothers / sisters also applied to Kuok Foundation Berhad this year? Jika ada, nyatakan nama adik-beradik
If yes, state name of brother / sister Institusi sedang dituntut / dipohonInstitution attending / applied to
Nama (Encik / Cik / Puan) Name (Mr / Miss / Mrs / Madam) Alamat
Address
No. telefon rumah
Home telephone no. No. telefon bimbitHandphone no. Poskod Postal code Bandar dan Negeri
City and State
Pekerjaan Occupation Alamat Address Poskod Postal code Bandar dan Negeri
City and State No. telefon rumah
Home telephone no. No. telefon bimbitHandphone no. Pekerjaan
Occupation No. telefon pejabatOffice telephone no. Pertalian dengan pemohon Relationship to applicant No. telefon pejabat
Office telephone no. Pertalian dengan pemohon
Relationship to applicant Jumlah tahun mengenali pemohonNo. of years known Jumlah tahun mengenali pemohon
No. of years known
Nama (Encik / Cik / Puan) Name (Mr / Miss / Mrs / Madam)
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 applicant’s family for a period of not less than 3 years. Referees can be relatives or close family friends BUT not applicant’s own parents, brothers / sisters or fellow students. Referees should be contactable by telephone during office hours.
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)
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.
Tarikh permohonan
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
APPLICANT’S REF. NO.
* F / M
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
-
1A
A+
3B
B+
7D
D
: Occ
-
A
4B
B
8E
E
: GY
-
2A
A-
5C
C+
9G
G
6C
C
Siblings’ GY
-
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
A
D
B-
R
C-
A-
C+
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 arrange your documents according to the order below)
PLEASE tick ( √√√ √) either “Yes” or “No”. If “No” please explain why under “Remarks”
Have you enclosed certified copies of Yes No Remarks
