KUOK FOUNDATION BERHAD(9641-T)

Letter Box No. 110, 16th Floor UBN Tower, 10 Jalan P Ramlee, 50250 Kuala LumpurTel: 03 - 2711 8428 E-mail: general@kuokfoundation.com Website: www.kuokfoundation.com

Borang permohonan untuk bantuan kewangan pelajaranApplication form for educational assistance

FOR OFFICE USE ONLYRECEIVED: REF. NO.:

REMARKS:

A MAKLUMAT PEMOHON / PARTICULARS OF APPLICANT

Gambar TERBARU Pemohon

RECENT Photograph of Applicant

ARAHANINSTRUCTIONS

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 perkahwinanMarital status

Alamat rumah (Tetap)Home address (Permanent)

No. telefon rumahHome telephone no.

No. telefon bimbitHandphone no.

Alamat e-mailE-mail address

Alamat surat-menyuratPostal address

Tarikh dan tempat lahirDate and place of birth

UmurAge

KewarganegaraanCitizenship

BangsaRace

Menuntut sepenuh masaStudying full-time

Bekerja tetapFull-time employment

Bekerja sementaraPart-time employment

Kedudukan sekarang pada masa pemohonanPresent status at time of application

PoskodPostal code

PoskodPostal code

Bandar dan NegeriCity and State

Bandar dan NegeriCity and State

LelakiMale

Perempuan Female

B BUTIR-BUTIR KURSUS / COURSE DETAILS

Yuran kursusTuition fees

Yuran lainOther fees

Tempat tinggalAccomodation

MakananFood

Perbelanjaan lainOther expenditure

JumlahTotal

Bilangan tahun bantuan diperlukanNo. of years assistance required

Sumbangan setahun daripada keluarga / sumber lain. Nyatakan sumberAmount 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 dituntutCourse applied (first choice) / Attending

Nama institusiName of institution

Lokasi institusiLocation of institution

Jangkamasa kursusDuration 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)NamaName

JantinaGender

UmurAge

Taraf perkahwinanMarital 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 sebulanGross monthly income

Kerja sepenuh masaFull-time employment

Kerja separuh masaPart-time employment

Perniagaan sendiriOwn business

BersaraRetired

Nama bapa / penjagaFather / Guardian’s name

Nama ibu Mother’s name

No. kad pengenalanNRIC number

UmurAge

No. kad pengenalanNRIC number

UmurAge

Alamat Address

No. telefon rumahHome telephone no.

No. telefon bimbitHandphone no.

PoskodPostal code

Bandar dan NegeriCity and State

Kerja sepenuh masaFull-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.

PekerjaanOccupation

Pendapatan kasar sebulanGross monthly income

Alamat Address

PoskodPostal code

Bandar dan NegeriCity and State

No. telefon rumahHome telephone no.

No. telefon bimbitHandphone no.

PekerjaanOccupation

Pendapatan kasar sebulanGross monthly income

No. telefon pejabatOffice telephone no.

No. telefon pejabatOffice telephone no.

D MAKLUMAT PENDIDIKAN / INFORMATION ON EDUCATION

E KEPUTUSAN PEPERIKSAAN / EXAMINATION RESULTS

F PENCAPAIAN KO-KURIKULUM / CO-CURRICULAR ACHIEVEMENTS

Butir-butir sekolah pemohon pernah belajarDetails of schools previously attended by applicant

Nama sekolahSchool name

Bandar dan NegeriCity and State

Tahun mulaYear commenced

Tahun tamatYear completed

Keputusan yang dicapaiQualifications obtained

Mata pelajaranSubject

SPM /SPVM / ‘O’ level atau kelayakan yang setaraf dengannyaSPM / SPVM / ‘O’ level or equivalent

Mata pelajaranSubject

GredGrade

TahunYear

STPM / ‘A’ level / Matrikulasi atau kelayakan yang setaraf dengannyaSTPM / ‘A’ level / Matriculation or equivalent

GredGrade

TahunYear

Keputusan peperiksaan universiti / kolej / politeknik seperti gred keseluruhan / purata nilai gred kumulatif, jika adaUniversity / college / polytechnic examination results such as overall grades / cumulative grade point average, if applicableTahun pertamaFirst year

Tahun keduaSecond year

Tahun ketigaThird year

Tahun keempatFourth year

Aktiviti-aktiviti semasa di sekolah / politeknik / kolej / universiti dan jawatan yang disandangActivities in school / polytechnic / college / university and leadership positions held

Anugerah / hadiah yang dimenangi seperti pencapaian akademik, sukan dan pertandingan lain di sekolah / politeknik / kolej / universitiPrizes / awards won such as academic / subject prizes, trophies, medals for sports / other competitions in school / polytechnic / college / university

G BANTUAN KEWANGAN / FINANCIAL ASSISTANCE

I LAIN-LAIN MAKLUMAT / OTHER INFORMATION

H MAKLUMAT PERUJUK / INFORMATION OF REFEREES

AdaYes

TidakNo

AdaYes

TidakNo

AdaYes

TidakNo

Butir-butir bantuan termasuk pinjaman yang anda terima terdahulu dan sekarang, jika ada, oleh organisasi-organisasi atau sumber-sumber lainDetails of past and present assistance including loans, if any, received from other organisations or other sources

Tahun diterimaYear 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 / pinjamanName 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 permohonanYear 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-beradikIf 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-beradikIf 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 rumahHome telephone no.

No. telefon bimbitHandphone no.

PoskodPostal code

Bandar dan NegeriCity and State

PekerjaanOccupation

Alamat Address

PoskodPostal code

Bandar dan NegeriCity and State

No. telefon rumahHome telephone no.

No. telefon bimbitHandphone no.

PekerjaanOccupation

No. telefon pejabatOffice telephone no.

Pertalian dengan pemohonRelationship to applicant

No. telefon pejabatOffice telephone no.

Pertalian dengan pemohonRelationship to applicant

Jumlah tahun mengenali pemohonNo. of years known

Jumlah tahun mengenali pemohonNo. 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 permohonanDate of application

Tandatangan pemohonApplicant’s signature

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

1. University / College / Polytechnic acceptance letter

2. Parents’ / Guardian’s proof of income for the past 2 years

3. Brothers’ and sisters’ proof of income for the past 2 years, if they are working

4. Letters or documents to prove that brothers and sisters are pursuing higher

education in universities / colleges / institutions

5. University / College / Polytechnic results (Actual/Forecast)

6. STPM / ‘A’ Level / Matriculation / Foundation (Actual/Forecast) & MUET results

7. SPM / SPVM / ‘O’ Level / UEC results (Actual/Forecast)

8. Identity card and birth certificate of applicant

9. Birth certificates of all brothers and sisters

10. Parents’ / Guardian’s identity cards or death certificate, if deceased

11. School leaving certificates

12. School testimonials (if any)

INSTRUCTIONS

PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY BEFORE FILLING DATA FORM

1. Please write or type clearly in BLOCK LETTER and complete DATA FORM in ENGLISH. 2. Please state “NA” in those sections which are not applicable to you. 3. The DATA FORM should be attached to the front page of the Kuok Foundation’s official

application forms. 4. In SECTION II, Nos. 1 & 2 you should state only your first choice of course and

university / college / polytechnic, if you are waiting for acceptance into university / college / polytechnic.

5. In SECTION II, No. 3, “Course Year” refers to whether you are in Year 1, 2 etc. in the new academic session.

6. In SECTION III, Nos. 1, 2 & 3, please state number of distinctions or credits or passes

obtained, for example :

SPM RESULTS 2009 TO COMPLETE IN THIS MANNER

Bahasa Melayu - A+ Bahasa Inggeris - A- Pendidikan Moral - B

Sejarah - A- Mathematics - B Additional Mathematics - C+ Physics - B+ Chemistry - B+ Biology - B+ Bahasa Cina - C+ English for Science - A

and Technology

1. *SPM / SPVM / ‘O’ Level results Year 2009

1A

A+ 1 3B B+ 3 7D D

A 1 4B B 2 8E E

2A A- 2 5C C+ 2 9G G

6C C

7. Please ensure that all sections of the application form have been completed. Incomplete application will be disqualified.

DEADLINE FOR SUBMISSION OF DOCUMENTS If any of the documents are not immediately available, please submit them within 1 month from the closing date for application.