Pidm 2011 Scholarship Award Application Form
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PIDM 2011 SCHOLARSHIP AWARD APPLICATION FORM
Please read the following instructions carefully before completing the application: 1. Each applicant is allowed to submit ONE application only. 2. All required supporting documents MUST be certified ‘true copies’ as per the original documents Please paste you by the relevant authorities. recent passport- 3. All fields in the form must be filled up properly and clearly and must not be left blank. State “Not sized photograph Applicable” or “‘NA” for areas that that are not applicable to you. here 4. Ensure your application is for courses at the public and/or private universities and/or colleges approved by PIDM only, for which you have gained acceptance to. 5. Please send the duly completed form with all the required supporting documents latest by 16 April 2011 to:-
General Manager, Human Capital (Scholarship Programme) Perbadanan Insurans Deposit Malaysia Level 12, Quill 7 No.9 Jalan Stesen Sentral 5 Kuala Lumpur Sentral, 50470 Kuala Lumpur
Or email your application to [email protected]
SECTION A PERSONAL DETAIL
Name as per NRIC :
Residential Address :
:
House Tel. No. : Mobile No. :
NRIC No. : Email Address :
Nationality : Race :
Religion : Date of Birth :
Gender : Marital Status :
SECTION B UNIVERSITIES AND FIELD OF STUDIES
N COURSES UNIVERSITIES O
1. 1.
2. 2.
3. 3.
PIDM SAF2011 Page 1 SECTION C EDUCATIONAL QUALIFICATION/EXTRA CURRICULAR ACTIVITIES
SPM or ‘O’ Level or equivalent:
Name of School :
Year Completed : Final Grade :
Detailed Grade:
NO SUBJECT GRADE NO SUBJECT GRADE
1. 11.
2. 12.
3. 13.
4. 14.
5. 15.
6. 16.
7. 17.
8. 18.
9. 19.
10. 20.
STPM or Matriculation or ‘A’ Level or equivalent: Name of School :
Year Completed : Final Grade :
Detailed Grade:
NO SUBJECT GRADE NO SUBJECT GRADE
1. 6.
2. 7.
3. 8.
4. 9.
5. 10.
PIDM SAF2011 Page 2 Other Qualifications or Awards Received
NO NAME OF QUALIFICATION OR AWARD RECEIVED AWARDED BY DATE OF AWARD
1.
2.
3.
4.
5.
Extra Curricular Activities
NO NAME OF SOCIETIES / CLUBS / SPORTS / OTHER ACTIVITIES POSITION HELD YEAR
SECTION D FAMILY & INCOME DETAILS
Legal Guardian, where applicable :
Father’s Name : Mother’s Name :
Age : Age :
NRIC No. : NRIC No. :
Occupation : Occupation :
Name of Employer : Name of Employer :
Address of Employer : Address of Employer :
Date Start : Date Start :
Office Tel. No. : Office Tel. No. :
Mobile No. : Mobile No. :
PIDM SAF2011 Page 3 SUMMARY OF INCOME [Please attach relevant documents, i.e. salary slip, statement of income, where applicable]
Immediate Family Members Nett Income (RM)
1. Legal Guardian, where applicable
2. Father
3. Mother
4. Applicant
Other sources of income (please specify)
5.
6.
7.
TOTAL
NAMES AND PARTICULARS OF SIBLINGS [Please use separate sheet if necessary]
No Name Age Please state occupation or Name of Please state if Nett Income if still studying School/College/University/ the person is in per month Employer receipt of a (RM) Scholarship from any Organisation
1.
2.
3.
4.
5.
Do you have relative(s) working at PIDM? If Yes, please furnish details: Yes ( ) No ( )
SECTION E FINANCIAL ASSISTANCE
Are you presently receiving any financial assistance from any institution / foundation / government, etc? If Yes, please furnish details: Yes ( ) No ( )
Have you applied for any other Scholarships/Grants/Educational Loan? If Yes, please furnish details: Yes ( ) No ( )
PIDM SAF2011 Page 4 SECTION F ESSAY
Please submit a written essay in English of approximately 1000 words on your chosen field and your aspirations in contributing to the financial services landscape and the country in general. [Please use separate sheets of papers if the column provided is not sufficient]
PIDM SAF2011 Page 5 PIDM SAF2011 Page 6 PIDM SAF2011 Page 7 PIDM SAF2011 Page 8 SECTION G REFEREES Please provide names, addresses, occupations and contact nos. of two (2) referees who are not related to you for us to contact as character references. Referee 1:
Name as per NRIC :
Residential Address :
:
House Tel. No. : Mobile No. :
NRIC No. : Email Address :
Referee 2:
Name as per NRIC :
Residential Address :
:
House Tel No. : Mobile No. :
NRIC No. : Email Address :
I, ______, I/C No. ______do hereby certify that all information provided in this application are true and accurate to the best of my knowledge and have not withheld any material information which might influence the consideration of this application. I understand that any misrepresentation/false declaration or omission will result in cancellation or withdrawal of any scholarship awarded. I also authorise any investigation of the above information for the purposes of verification.
______Applicant’s Signature Date
FOR OFFICE USE ONLY
Date Application Received & Received by :
Shortlisted for interview Yes No
Comments:-
PIDM SAF2011 Page 9 CHECKLIST Please ensure all the documents listed below are included in your scholarship application submission:-
Completed application form Certified true copy of National Registration Identification Card (Both Sides on A4 paper) Certified true copy of Sijil Pelajaran Malaysia transcript Certified true copy of applicant’s/parents’/guardian’s most recent EA/BE Form/Payslips Tax Return Form /any other proof of income 1000 word essay Recent passport-sized colour photograph Acceptance/Offer Letter by University or private college to undertake a field of study as approved by PIDM
PIDM accepts documents that are certified by any of the following individual:- 1. Grade A Government Officer 2. School Principal/Headmaster 3. Commissioner of Oath 4. “Ketua Kampung” 5. “Ahli Jawatankuasa Kemajuan dan Keselamatan Kampung” 6. The employer or authorised representative of the employer
PIDM SAF2011 Page 10