APPLICATION FOR SCHOLARSHIP OF IEM EDUCATION FUND
APPLICATION FOR SCHOLARSHIP OF IEM EDUCATION FUND
APPLICATION FOR SCHOLARSHIP OF IEM EDUCATION FUND
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THE INSTITUTION <strong>OF</strong> ENGINEERS, MALAYSIA<br />
Bangunan Ingenieur, Lots 60 & 62, Jalan 52/4, P.O. Box 223, Jalan Sultan, 46720 Petaling Jaya<br />
Tel: 03-79684001/4002 Fax: 03-79577678 e-mail: sec@iem.org.my<br />
Homepage:http//www.iem.org.my<br />
<strong>APPLICATION</strong> <strong>FOR</strong><br />
<strong>SCHOLARSHIP</strong> <strong>OF</strong><br />
<strong>IEM</strong> <strong>EDUCATION</strong> <strong>FUND</strong><br />
Photo<br />
(TAN SRI IR. HJ. YUS<strong>OF</strong>F HJ. IBRAHIM <strong>SCHOLARSHIP</strong> –<br />
UNIVERSITI TEKNOLOGI MALAYSIA)<br />
1. NAME ………………………………………………………………………….…..………………<br />
DATE <strong>OF</strong> BIRTH …………………... (D/M/Y) SEX ………… AGE ……………………<br />
2 IDENTITY CARD NO. (NEW) ………………….. - ..…… - …..……… (OLD) …………….………<br />
3 UNIVERSITY …………………………………………………………………………………………..….<br />
4 CURRENT YEAR <strong>OF</strong><br />
STUDY<br />
…………………..<br />
(1, 2, 3, 4)<br />
ENGINEERING<br />
DISIPLINE<br />
………………………………..………<br />
Session: 20 ………../ 20……..…<br />
5 SPM EXAMINATION RESULTS : Year sat : ……………… Division (Bahagian) ………………….<br />
Subject Grade Subject Grade<br />
……………………………………………………….…...<br />
…………………………………………………….……...<br />
…………………………………………………….………<br />
…………………………………………………….……..<br />
…………………………………………………….……..<br />
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additional paper : Year taken …………………………<br />
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6 STPM/DIPLOMA* EXAMINATION RESULTS<br />
Subject Year sat Paper Grade Alphabet Grade<br />
……………………………………………………………………………..……………………………………………….<br />
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*delete where not applicable
7 UNIVERSITY EXAMNIATION RESULTS<br />
Number (Bilangan) of alphabetical grades<br />
Year of Study Session A+ A B C D E F<br />
………………………………………………………………………………………………………………………………<br />
………………………………………………………………………………………………………………………………<br />
8 OTHER ACADEMIC QUALIFICATIONS<br />
Examination Body Stage of Examination Year Sat Result<br />
………………………………………………………………………………………………………………………..…….<br />
………………………………………………………………………………………………………………………………<br />
9 LIST ANY AWARDS/PRIZES/MEDALS RECEIVED<br />
Name of Awards Awarded by Year of Award<br />
………………………………………………………………………………………………………………………………<br />
………………………………………………………………………………………………………………………………<br />
10 EXTRA - CURRICULAR ACTIVITIES<br />
………………………………………………………………………………………………………………………………<br />
………………………………………………………………………………………………………………………………<br />
11 FAMILY BACKGROUND<br />
(a) Name of Father/Guardian * : ……………………………………………………… Age : ………..<br />
Address :<br />
……………………………………………………………………………………………….……………..<br />
…………………………………………………………………………………………………..…………..….……………<br />
Telephone No. :<br />
(house) ……………………….… (office) …………………..… (mobile) ………………….<br />
Occupation : ……………………………… Salary/Income per month RM ………….…………...<br />
Name & Address of Father’s Employer:<br />
………………………………………………………………………...<br />
……………………………………………………………………………………………………………………………….<br />
……………………………………………………………………………………………………………………………….<br />
(b) Name of (Mother, Brothers & Sisters) Age Occupation Salary/Income per<br />
Month<br />
………………………………………………………………………………………………………<br />
………………………………………………………………………………………………………<br />
………………………………………………………………………………………………………<br />
………………………………………………………………………………………………………<br />
………………………………………………………………………………………………………<br />
RM ……………<br />
RM ……………<br />
RM ……………<br />
RM ……………<br />
RM ……………<br />
(c) Total family income per month : RM …………………………………….<br />
How much financial assistance can your family offer you per month? RM …………………………...<br />
*delete where not applicable
(d)<br />
Particulars of two Referees with whom the <strong>IEM</strong> can check on your character and family background<br />
Name Occupation Address & Telephone No.<br />
1. ……………………………………………………………………………………………………………………….<br />
……………………………………….…<br />
………………………………………….<br />
2. ……………………………………………………………………………………………………………………….<br />
……………………………………….…<br />
………………………………………….<br />
(e)<br />
Provide any other information on your family financial status which may be helpful towards your loan<br />
application:<br />
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*delete where not applicable
12 YOUR PERMANENT HOME ADDRESS<br />
………………………………………………………………………………………………………………………………<br />
………………………………………………………………………………………………………………………………<br />
Telephone No.<br />
(house) ……………………….… (office) …………………..… (mobile) ………………….<br />
YOUR LOCAL CORRESPONDENCE ADDRESS (POSTAL ADDRESS)<br />
………………………………………………………………………………………………………………………………<br />
………………………………………………………………………………………………………………………………<br />
Telephone No.<br />
(house) ……………………….… (office) …………………..… (mobile) ………………….<br />
13 DECLARATION<br />
I certify that the information provided in this application is to the best of my knowledge true and correct.<br />
I understand that should any information so provided be found false, my scholarship if approved would be<br />
cancelled and repayable to the <strong>IEM</strong> forthwith.<br />
I declare I am also not the Recipient of any scholarship, loan, bursary, etc, for the current course of study in<br />
which I am undertaking.<br />
……………………………………<br />
(Date)<br />
………………………………………<br />
(Signature of Applicant)<br />
NOTE TO APPLICANT<br />
Please refer to the Check-list and submit application to reach before deadline announced, to:<br />
HON. SECRETARY<br />
<strong>IEM</strong> BOARD <strong>OF</strong> <strong>EDUCATION</strong> <strong>FUND</strong><br />
C/o The Institution of Engineers, Malaysia<br />
Bangunan Ingenieur,<br />
Lots 60 & 62, Jalan 52/4,<br />
P.O.Box 223, (Jalan Sultan),<br />
46720 Petaling Jaya,<br />
Selangor Darul Ehsan.<br />
Telephone No. 6-03-79684001 or 6-03-79684002<br />
Fax No. : 03 – 7957 7678<br />
*delete where not applicable
THE INSTITUTION <strong>OF</strong> ENGINEERS, MALAYSIA<br />
<strong>APPLICATION</strong> <strong>FOR</strong><br />
<strong>SCHOLARSHIP</strong> <strong>OF</strong> <strong>IEM</strong> <strong>EDUCATION</strong> <strong>FUND</strong><br />
Check List<br />
√<br />
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………………….<br />
………………….<br />
………………….<br />
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………………….<br />
Item (one each)<br />
University admission letter (certified copy)<br />
Certification letter from Faculty (see below)<br />
Birth Certificate and Identification Card (certified copy)<br />
SPM Examination result slip(s) (certified copy)<br />
STPM/Diploma Examination result slip(s) (certified copy)<br />
University academic transcripts (certified copy)<br />
Other qualifications & awards (certified copy)<br />
Latest J Form of Father / Guardian<br />
Testimonials (certified copy)<br />
Please inform the Institution of any change in your correspondence address<br />
*delete where not applicable
UNTUK DI ISI OLEH WAKIL UNIVERSITI<br />
Setiausaha Kehormat<br />
Institusi Jurutera Malaysia<br />
Bangunan Ingenieur<br />
Lots 60 & 62, Jalan 52/4,<br />
P.O.Box 223, (Jalan Sultan),<br />
46720 Petaling Jaya,<br />
Selangor Darul Ehsan.<br />
Dengan ini disahkan bahawa ………………………………………………………… (K/P: ………………………………………)<br />
adalah pelajar berdafter : Bil: ………………………………………………………… di<br />
Universiti :<br />
Fakulti :<br />
Jurusan :<br />
Tahun :<br />
Sessi :<br />
Bilangan semester/penggal setahun akademik : ……………………………………………………………………………………...<br />
Bayaran yuran berkenaan sesemester/penggal : ……………………………………………………………………………………...<br />
……………………………<br />
(Tarikh)<br />
……………………………………………………………..<br />
( )<br />
*delete where not applicable
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