Application Form - IOI Group

YAYASAN TAN SRI LEE SHIN CHENGCompany No. 139943-UBorang Permohonan Bantuan Kewangan untuk Pembelajaran di Institusi Pengajian TinggiApplication Form for Higher Education AssistanceGambarTERBARUPemohonRECENTPhotograph ofApplicantARAHANINSTRUCTIONS1. Taip atau tulis dengan jelas. Gunakan HURUF BESAR.2. Taip atau tulis name penuh anda sepertimana yang terdapat didalamkad pengenalan anda. Gariskan nama keluarga anda.3. Pemohon yang telah memasuki universiti hendaklah menyatakantahun pengajian sama ada Tahun 1, Tahun 2 dan seterusnya atauTahun terakhir bagi sessi akan datang.4. Sekiranya ibu bapa telah bersara, tulis dalam kurungan jenispekerjaan, nama dan alamat majikan/perniagaan sendiri merekasebelum bersara. Jika telah meninggal dunia, lampirkan salinan sijilkematian dan nyatakan juga pekerjaan, nama dan alamatmajikan/perniagaan sendiri semasa hayatnya.5. Sekiranya ruang menulis tidak mencukupi, gunakan kertas tambahandan lampirkan bersama borang permohonan.6. Salinan-salinan yang telah disahkan bagi sijil beranak, sijil-sijilpeperiksaan dan lain-lain dokumen yang berkaitan seperti notistaksiran cukai pendapatan ibu bapa/penjaga hendaklah dilampirkan.7. Borang permohonan yang telah lengkap hendaklah dikembalikansebelum 27hb Julai 2013 kepada: -SekretariatYAYASAN TAN SRI LEE SHIN CHENGLevel 11, Two IOI Square, IOI Resort,62502 Putrajaya,Malaysia1. Please type or write clearly. Please use BLOCK LETTERS.2. Type or write your name in full as it appears in your NRIC andunderline your surname.3. Those who are already in the University should state whether theyare in Year 1, Year 2, etc or final year in the coming session.4. If parent/parents are retired, state within brackets their occupation,name and address of employer/own business before retirement, ifdeceased. Kindly submit death certificate and state formeroccupation, name and address of employer/own business.5. If space is insufficient, please continue in a separate sheet andattach the sheet to the application form.6. Certified copies of birth certificate, examination certificates and otherrelevant documents such as income tax notice of assessment ofparents/guardians must be attached.7. Completed application form should be returned by27 th July 2013 to:-SecretariatYAYASAN TAN SRI LEE SHIN CHENGLevel 11, Two IOI Square, IOI Resort,62502 Putrajaya,MalaysiaA – MAKLUMAT PEMOHON / PARTICULARS FOR APPLICANTNama pemohon (Encik /Cik / Puan)Name of applicant (Mr / Miss / Mrs /Madam)Alamat rumah (Tetap)Home address (Permanent)Alamat surat-menyuratCorrespondence addressNo. Kad pengenalanNRIC numberBandar dan NegeriCity and StatePoskodPostal codeBandar dan NegeriCity and StatePoskodPostal codeNo. tel rumahHome tel no.No. tel bimbitH/p No.Alamat e-mailE-mail addressTarikh dan tempat lahirPlace and date of birthUmurAgeKewarganegaraanCitizenshipKedudukan sekarangPresent statusJika menuntut, nyatakan peringkat pendidikanIf studying, state level of educationJika mahasiswa nyatakan tahun kursus bagi sessi akan datangIf in University, state year of course in the coming sessionJika sedang bekerja, nyatakan pekerjaanIf currently employed, state occupationJumlah tahun telah bekerjaNo. of years employmentGaji terakhir diterima sebulanLast drawn salary per month

B – BUTIR-BUTIR KURSUS / COURSE DETAILSKursus dipohon (pilihan pertama) / Sedang dituntutCourse applied (first choice) / AttendingNama institusiName of institutionJangkamasa kursusDuration of courseMula kursusCommencement of course (mm/yyyy)Lokasi institusiLocation of institutionTamat kursusCompletion of course (mm/yyyy)Butir-butir perbelanjaan diperlukan setahun (nyatakan dalan Ringgit Malaysia)Breakdown of estimated expenses required per annum (in Malaysian Ringgit)Yuran kursusTuition fees (RM)Yuran lainOther fees (RM)Tempat tinggalAccommodationMakananFoodPerbelanjaan lainOther expenditureJumlahTotal (RM)Bilangan tahun bantuan diperlukanNo. of years assistance requiredSumbangan setahun daripada keluarga / sumber lain. Nyatakan sumber.Amount per annum which can be obtained from family / other sources. State sourcesJumlah bantuan dipohon setahunAmount applied for per annum (RM)C – MAKLUMAT KELUARGA / INFORMATION ON FAMILYNama bapa / penjagaNama ibuFather/Guardian’s nameMother’s nameNo. kad pengenalanNRIC numberUmurAgeNo. kad pengenalanNRIC numberUmurAgeAlamatAddressAlamatAddressNo.tel rumahHome tel no.PekerjaanOccupationNo.tel bimbitH/p no.Pendapatan kasar sebulanGross income per monthNama serta alamat majikan / perniagaan sendiri (jika sudah bersara, nyatakan jenispekerjaan, nama dan alamat majikan / perniagaan yang terdahulu)Name and address of employer / own business (if retired, state type of employment,name and address of previous employer / own business)No.tel rumahHome tel no.PekerjaanOccupationNo.tel bimbitH/p no.Pendapatan kasar sebulanGross income per monthNama serta alamat majikan / perniagaan sendiri (jika sudah bersara, nyatakan jenispekerjaan, nama dan alamat majikan / perniagaan yang terdahulu)Name and address of employer / own business (if retired, state type of employment,name and address of previous employer / own business)No. tel pejabatOffice tel no.No. tel pejabatOffice tel no.Butir-butir SEMUA adik beradik (kecuali pemohon)Particulars of ALL brothers and sisters (exclude applicant)NamaNameJantinaSexUmurAgeTarafperkahwinanMarital statusBil. anak,(jika ada)No ofchildren(if any)Pekerjaan (jika menuntut,nyatakan peringkat pendidikandan mana sekolah/institusi)Occupation (if studying, statelevel of education and name ofschool/institution)No tel (rumah, H/patau Pejabat)Tel no (home, H/por office)Pendapatankasar sebulanGross incomeper month

D – MAKLUMAT PENDIDIKAN / INFORMATION ON EDUCATIONButir-butir sekolah pemohon pernah belajarDetails of schools previously attended by applicantNama sekolahSchool nameBandar & NegeriCity & StateTahun mulaYearcommencedTahun tamatYearcompletedKeputusan yang dicapaiQualifications obtainedE – KEPUTUSAN PEPERIKSAAN / EXAMINATION RESULTSSPM / SPVM / ’O’ level atau kelayakan yang setaraf dengannyaSPM / SPVM / ‘O’ level or equivalentMata pelajaranSubjectsTahunYearGredGradeSTPM / ’A’ level / Matrikulasi atau kelayakan yang setarafdengannyaSTPM / ’A’ level / Matriculation or equivalentMata pelajaranSubjectsTahunYearGredGradeKeputusan peperiksaan universiti/ kolej seperti gred keseluruhan / purata nilai gred kumulatif, jika adaUniversity / college examination results such as overall grades / cumulative grade point average (if applicable), attach result slipTahun 11 st yearTahun 22 nd yearTahun 33 rd yearTahun 44 th yearF – PENCAPAIAN KO-KURIKULUM / CO-CURRICULAR ACHIEVEMENTSAktiviti-aktiviti semasa di sekolah / kolej / universiti dan jawatan yang disandangActivities in school / college / university and leadership positions heldAnugerah / hadiah-hadiah yang dimenangi seperti pencapaian akademik, sukan dan lain-lain pertandinganPrizes / awards won such as academic / subject prizes, trophies, medal for sports / other competitions

G – BANTUAN KEWANGAN / FINANCIAL ASSISTANCEButir-butir bantuan termasuk pinjaman yang diterima dahulu dan sekarang, jika ada, oleh organisasi-organisasi sumber-sumber lain.Details of past and present assistance, including loans, if any, received from other organizations or other sourcesTahun diterimaYear receivedPinjaman atau biasiswaLoan or scholarshipNama organisasi / sumber lainName of organization / other sourcesJumlah setahunAmount per annumNamakan organisasi-organisasi lain yanganda pernah memohon biasiswa / pinjamamName other organizations you have applied tofor scholarship/loanPernahkah anda memohon bantuan kewangan dari Yayasan TSLSC?Have you previously applied to the TSLSC Foundation?Jika pernah, nyatakan tarikh permohonanIf yes, state date of applicationJumlah bantuan diterima, jika adaAmount of assistance received, if anyAdaYesTidakNoAdakah adik-beradik anda menerima kewangan dari Yayasan TSLSC?Are any of your brothers/sisters assisted by TSLSC Foundation?Jika ada, nyatakan nama adik-beradikIf yes, state name of brother / sisterTahun dan jenis bantuanYear Assisted and Type of AwardAdaYesTidakNoAdakah adik-beradik anda memohon kewangan dari Yayasan TSLSC tahun ini?Have any of your brothers/sisters also applied to TSLSC Foundation this year?Jika ada, nyatakan nama adik-beradikIf yes, state name of brother / sisterInstitusi sedang dituntut / dipohonInstitution attending / applied toAdaYesTidakNoH – MAKLUMAT PERUJUK – INFORMATION ON REFEREESNamakan dua perujuk yang mengenali pemohon dan keluarga pemohon sekurang-kurangnya 3 tahun. Perujuk boleh terdiri daripada saudara-mara atau kawan rapat keluargaTETAPI bukan daripada kalangan penuntut, ibubapa atau adik-beradik pemohon. Perujuk mestilah boleh dihubungi melalui telefon semasa waktu pejabat.Names 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 notapplicant’s own parents, brothers / sisters or fellow students. Referees should be contactable by telephone during office hours.Nama (Encik / Cik / Puan)Nama (Encik / Cik / Puan)Name (Mr / Miss / Mrs / Madam)Name (Mr / Miss / Mrs / Madam)AlamatAddressAlamatAddressBandar dan NegeriCity and StatePoskodPostal codeBandar dan NegeriCity and StatePoskodPostal codeNo. tel rumahHome tel noNo. tel bimbitH/p no.No. tel rumahHome tel noNo. tel bimbitH/p no.PekerjaaanOccupationNo. tel pejabatOffice tel no.PekerjaaanOccupationNo. tel pejabatOffice tel no.Jumlah tahun mengenali pemohonNo. of years knownPertalian dengan pemohonRelationship to applicantJumlah tahun mengenali andaNo. of years knownPertalian dengan pemohonRelationship to applicantI – LAIN –LAIN MAKLUMAT / OTHER INFORMATIONKenyataan lain untuk menyokong permohonan iniOther relevant information to support your applicationMengapa anda memilih kursus pelajaran ini?Why did you choose the course of study?Saya mengakui bahawa maklumat-maklumat yang diberikan adalah benar dan saya tidak ada dengan sengajanya menyembunyikan apa-apa maklumat yangdikehendaki 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 willfully suppressed any material fact relevant tothis application._______________________Tandatangan pemohonApplicant’s signature___________________Tarikh permohonanDate of applicationNota: Pihak Yayasan berhak menolak dan membatalkan tawaran biasiswa sekiranya Pemohon didapati memberi sebarang maklumat palsu atau menyembunyikan sebarangmaklumat.Note: The Yayasan reserves its right to reject and to nullify its offer of scholarship/grant to any Applicant found to have provided any false information and/or withheld anymaterial fact.

YAYASAN TAN SRI LEE SHIN CHENG – DATA CHECKLIST (To attach this to the front page of Application Form)Please check and fill in accordingly.I NAME OF APPLICANT SEX*F / MIIPARTICULARS OF COURSE1. Name of Course2. Name of * University /College*Applied / Attending3. Course Year (in the coming academic session)IIIEXAMINATION RESULTS (Do not write in shaded boxes)1. *SPM / SPVM / ‘O’ Level results Year1AA+ 3B B+ 7D DA 4B B 8E E2A A- 5C C+ 9G G6C C2. UEC results YearA1 B3 B5 C7A2 B4 B6 C8UEC refers to Unified Examination Certificate for Independent Chinese Secondary Schools in Malaysia.3. *STPM / ‘A’ Level results YearAAB-C-DA- C+ R D+B B+ E C DCB4. Matriculation results Year 5. MUET results*CGPA / Overall GradeBand6. Latest *University / College results Year*CGPA / Overall Grade*Delete whichever is not applicableDOCUMENTS CHECKLIST (Please arrange your documents according to the order below)Please tick either “Yes or “No. If “No” please explain why under RemarksHave you enclosed Certified True Copies of Yes No Remarks1 University/College acceptance letter2 Document stating the course fee from the University3 Academic Calendar4 I/C or Birth Certificate of applicant5 SPM / SPVM / 'O' Level / UEC results6 STPM / 'A' Level / Matriculation / Foundation results7 University/College results8 School Leaving Certificates9 School Testimonials (if any)10 Parents' / Guardian's proof of income for the past 1 year11 Letter or documents to prove that brothers and sisters are pursuinghigher education in universities/colleges