Application Form CS.pdf

8/10/2019 Application Form CS.pdf

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UBD Chancellors Scholarship 1

For OFFICIAL USE ONLY

App No.

UBD CHANCELLORS SCHOLAR

APPLICATION FORM

FORM CS-01

Universiti Brunei Darussalam

Please return your completed application form to the following address before the closing date for application: -

UBD Chancellors Scholar Secretariat

Administration BuildingUniversiti Brunei Darussalam

Jalan Tungku Link

Gadong BE1410

Brunei Darussalam

www.ubd.edu.bn

Tel: +673-2463001 Ext 1160/1900/1653 Fax: +673-2460757

Email:[email protected] Website:http://www.ubd.edu.bn

You are required to submit one set of the completed application. Each application includes: -

1. Completed application form (CS-01)

2. Two recent passport-sized photographs

3. Supporting documents as per checklist at the end of this application form

NOTE: Certified English translations must be submitted for supporting documents that are not in the English Language. Online application is currently

not available.

PERSONAL PARTICULARS (Please print in BLOCK letters)

NameMr /Miss _________________________________________________________________(As in Identity Card)

____________________________________________________________________________________

IC No. _______ -__________________ Colour ________________________

Nationality ______________________ Ethnic Group ___________________

Date of Birth ____________________ Birthplace _____________________ Age________(dd/mm/yy)

Religion ________________________ Domicile ________________________________________(Country you live in permanently)

Passport No. _____________ Place of Issue _____________ Date of Isssue __________ Date of Expiry _______________(dd/mm/yy) (dd/mm/yy)

Permanent Home Address _______________________________________________________________________________________

____________________________________________________________________________________________________________

Contact No (s) ____________________ Home ____________________Mobile ____________________ Fax*

Mailing Address ______________________________________________________________________________________________(if different from above)

___________________________________________________________________________________________________________

Other Contact No(s) ______________________________ Email* __________________________________________

*Applicants are strongly advised to provide either a fax no. or an e-mail address to facilitate correspondence)

Please attach 2x recent

passport size photograph
http://www.ubd.edu.bn/http://www.ubd.edu.bn/mailto:[email protected]:[email protected]:[email protected]://www.ubd.edu.bn/http://www.ubd.edu.bn/http://www.ubd.edu.bn/http://www.ubd.edu.bn/mailto:[email protected]://www.ubd.edu.bn/


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FAMILY INFORMATION

Name of Parent / Guardian ______________________________________________________________________________________

Male Female (As in Identity Card)

IC No. _______ -__________________ Colour ________________________ Ethnic Group _______________________

Occupation __________________________________ Appointment __________________________________________

Employer __________________________________________________________________________________________

Mailing Address _____________________________________________________________________________________

__________________________________________________________________________________________________

Contact No(s) ________________ Home _________________ Mobile ____________________ Office

Fax ____________________________ Email ____________________________________________

Name of Parent / Guardian ______________________________________________________________________________________

Male Female (As in Identity Card)

IC No. _______ -__________________ Colour ________________________ Ethnic Group _______________________

Occupation __________________________________ Appointment __________________________________________

Employer __________________________________________________________________________________________

Mailing Address _____________________________________________________________________________________

__________________________________________________________________________________________________


Fax ____________________________ Email ____________________________________________

Have any of your family members received the UBD Chancellors Scholarship or from Ministry of Education Goverment Scholarship in

the past? Yes No

If yes, please list their names, relationship to you and year of award.

1.

______________________________________________________________________________________________________

2.

______________________________________________________________________________________________________

3.

______________________________________________________________________________________________________

Do you have family members currently employed by Universiti Brunei Darussalam? Yes No

If yes, please list their names, rank, current posts and their relationship to you.

1.

______________________________________________________________________________________________________

2. ______________________________________________________________________________________________________

3. ______________________________________________________________________________________________________


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EDUCATIONAL BACKGROUNDPlease indicate Examining Board where appropriate, e.g. Cambridge Examination Board / London Examination Board / International

Baccalaureate and/or Equivalent. Please submit official true copies results / transcripts.

First / Masters Degree

University ___________________________________________________________________________________________________

Address ______________________________________________________________________________________________________

_____________________________________________________________ Contact No. _____________________________________

Fax _____________________________ Email ____________________________________________________________________

Reason for leaving _____________________________________________________________________________________________

Date of Attendance (From) ___________________________________________ (To) _______________________________________(mm/yyyy) (mm/yyyy)

Date(mm/yyyy)

Subject(Taken / will be taking)

Semester Numerical and/or

Level Grade


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GCE A / AS Level / STPUB / IB or Equivalent

School / College / Institutions _____________________________________________________________________________________

Address ______________________________________________________________________________________________________

_____________________________________________________________ Contact No. _____________________________________

Fax _____________________________ Email ____________________________________________________________________

Reason for leaving _____________________________________________________________________________________________

Date of Attendance (From) ___________________________________________ (To) _______________________________________(mm/yyyy) (mm/yyyy)

Date(mm/yyyy)

Subject(Taken / will be taking)

Examining Board Level(A/AS)

Numerical and/or

Level Grade

PROFESSIONAL QUALIFICATION / CERTIFICATIONList your current and most recent qualification / certification and first and submit documentary evidence.

From(dd/mm/yyyy)

To(dd/mm/yyyy)

Organisation / Institution / Location Certificate (C) / Diploma (D) Grade

E.g. 01/01/2000 07/01/2000 Informatics (Singapore) NETWORK + (C) Pass


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ACADEMIC, FINANCIAL AND SPORTING AWARDSE.g. honours, distinctions, book prizes won. Please list in chronological order (since Form 4 or equivalent) and submit documentary

evidence.

Date(mm/yyyy)

Award Awarded by

EXTRA-CURRICULUAR AND CIVIC OR COMMUNITY ACTIVITIESPlease list in order of importance and submit documentary evidence.

Activity Office /

Position Held

Elected /

Appointed /

Voluntary

Level (School /

District /

National)

Active Dates

(dd/mm/yy)


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WORK EXPERIENCEList your current and/or most recent position (if any).

Position ______________________________________________ Organisation _________________________________________

Date Employed (From) _______________________ (To) ______________________________ Part Time / Full Time(dd/mm/yy) (dd/mm/yy)

Responsibilities Held ____________________________________________________________________________________________

_____________________________________________________________________________________________________________

Nature of Organisation: Government Non-Profit Private Sector

Mailing Address ________________________________________________________________________________________________

Contact No. ______________________________ Fax No. ____________________________ E-mail _________________________

VOLUNTARY SERVICE

List your current and/or most recent position (if any).

Position ______________________________________________ Organisation _________________________________________

Date Volunteered (From) _______________________ (To) ____________________________ Part Time / Full Time(dd/mm/yy) (dd/mm/yy)

Responsibilities Held ____________________________________________________________________________________________

_____________________________________________________________________________________________________________

Nature of Organisation: Government Non-Profit Private Sector

Mailing Address ________________________________________________________________________________________________

Contact No. ______________________________ Fax No. ____________________________ E-mail _________________________


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COURSES AND UNIVERSITIESPlease list the course and university you wish to apply to in the order of preference and remark appropraitely if you have submitted

your application to them (please submit proof of application if you have already done so). Note that you must gain admission to the

Universities specified in order to be considered for the scholarship.

Choice Course of Study University Location Application

Submitted

Outcome of

Applciation

E.g. Poticial Science Harvard University (USA) YN Awaiting Reply

1 YN

2 YN

3 YN

4 YN

5 YN

6 YN

7 YN8 YN

OTHER AWARDS / FINANCIAL ASSISTANCE SCHEMESHave you applied for any other Scholarships / Bursaries / Loans from any other organisations? Yes No

If yes, please furnish the following details:

Name of Award / Loan __________________________________________________________________________________________

Outcome of application: Successful Unsuccessful Awaiting Offer

Duration of Award ___________________________________ Amount Granted _____________________________________

Approved Institution of Study ___________________________________________________________________________________

Any other Information _________________________________________________________________________________________

PREVIOUS APPLICATIONHave you previously applied for this Scholarship before? Yes No


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STANDARDISED TEST INFORMATIONPlease provide your TOEFL, SAT I and SAT II scores below. Note that you will need to sit for TOEFL and the SAT I in order to be

considered into most US Colleges / Universities some will also require the SAT II (please check with the university that you plan to

apply to). If you have booked a place in these said tests, please indicate the date(s) which you will be dong them. Please provide

highest scores.

I have not applied for the TOEFL I will be taking the TOEFL

I have taken the TOEFL

Date (mm/yyyy) ___________________________ Date (mm/yyyy) _______________________________

Listening Score ___________________________

Writing Score ___________________________

Reading Score ___________________________

Total Score ___________________________

I have not applied for the SAT I I will be taking the SAT I

I have taken the SAT I


Critical Reading Score ____________________

Math Score ___________________________

Writing Score ___________________________

Total Score ___________________________

I have not applied for the SAT II I will be taking the SAT II

I have taken the SAT II


Subject and Score ________________________





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REFERENCESPlease provide the details of at least 2 referees below. Referee reports are to be completed by your Dean, Lecturer and/or

Club/Organisation Leader. The Referees report must be submitted in a sealed envelope with the referees signature across the flap of

the envelope.

Name ____________________________________________________ Position ___________________________________

Address of Organisation / Institution ________________________________________________________________________

_____________________________________________ Contact No. ___________________ Fax No. _______________

Email _______________________________________________________________________________________________

Name ____________________________________________________ Position ___________________________________


_____________________________________________ Contact No. ___________________ Fax No. _______________

Email _______________________________________________________________________________________________

Name ____________________________________________________ Position ___________________________________


_____________________________________________ Contact No. ___________________ Fax No. _______________

Email _______________________________________________________________________________________________


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DECLARATION

Have you ever been convicted by a Court of law of any country? Yes No

If yes, please give details:

____________________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

_____________________________________________________________________________________________________

I hereby declare that the information provided in this application is correct and the attachments are true to the best of my knowledge

and belief, and I have not witfully suppressed any material fact. I authorise Universiti Brunei Darussalam to obtain official records, if

necessary, from any educational institution I have attended.

As far as I am aware, I am medically fit and free from any medical problem which may impair my ability to attend to my studies.

I understand that any provision of inaccurate and false information or omission of information will render this applciation invalid and

that, if admitted on the basis of such information, I can be required to withdraw from the Scholarship.

Signature _____________________________________ Date ___________________________

FOR OFFICE USE ONLY

Date Received: Application No:


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ATTACHMENT 1ESSAY

Please note that the essay is an important part of your Scholarship application. Please attach (not staple) a typed or computer-

generated copy in thte space below. We strongly prefer that you do not handwrite your responses.

Write a short essay on who you are and what you are passionate about (400-500 words). The essay has to be an original piece, and no

part of it may be copied.


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CONFIDENTIAL

ATTACHMENT 2FACULTY DEAN REFERENCE FORM

TO THE APPLICANT

Please fill in the personal information below and forward this form to your current or previous Faculty Dean. Each reference must be

put in a sealed envelope, signed across the seal by the referee and returned to you by submission with your scholarship application

package.

PERSONAL INFORMATION



Other Contact No (s) ______________________________________ Email ______________________________________________

University / Institution now /previously attended ____________________________________________________________________

TO THE FACULTY DEAN

The applicant has applied for the Universiti Brunei Darussalam Chancellors Scholarship. Please complete and return this form in a

sealed envelope to the applicant, who will forward it, unopened to the Scholarship Office, Universiti Brunei Darussalam. When you

seal the envelope, please sign across the seal.

Please write as fully as you can about the applicant from your perspective in providing us with but not limited to:

i.

Relevant factual data about the applicants academic performance and elevel fo extra-curricular achievement;

ii. Your impressions of the candidates personal qualities and contribution to your school community; and

iii.

Information about personal circumstances that might have disadvantaged the applicant.

If you prefer to send a letter or statement (on the Universitys / Institutionsletterhead and/or stamped), please feel free to do so.

Please check the rating boxes and include your letter or statement with this form and return both to Scholarship Office, Universiti

Brunei Darussalam. We appreciate the effort you expend on behalf of your student applying for this scholarship.

Name of person completing this report _____________________________________________________________________________

Position ___________________________________ University / Institution _______________________________________________

Contact No ___________________ Fax _____________________ Email ________________________________________

Signature _________________________________ Date _______________________________________________

University Code (if any) __________________________________

This report is based on (check all that apply): Personal contact with student Lecturers Observation

Records Others ____________________________________________________________________________________

How long have you known this applicant? ________________________________________________________________________

In what capacity? ___________________________________________________________________________________________

How often do you meet with this applicant? ______________________________________________________________________

How well do you know this applicant? ___________________________________________________________________________


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TRANSCRIPT Please include an official copy of the applicants transcript of work completed from their Undergraduate (or the

equivalent).A brief explanation of titles or unusual grading systems would greatly assist us in assuring an accurate assessment of the

applicants level of achievement.

1. ACADEMIC / INTELLECTUAL

In what way might you distinguish this applicants academic performance from that of other university -bound students?

Either through personal experience or in talking with lecturers, how would you characterise this applicants level of

intellectual curiosity and approach to learning?

2. PERSONAL / INTERPERSONAL

a.

What do you like best about this applicant? In what ways has this applicant made an impact either in your University/

Institution or in the community?

b.

Are there any factors that might interefere with teh applicants academic performance and/or personal relationship

during his/her couorse of study

3.

ADDITIONAL INFORMATION

a. Is there anything else we should know about this applicant (e.g. personal circumstances, character, values, a point of

interest or concern, particular interests, unusual accomplishments / special talents, obstacles overcame?)

Yes (Please explain fully on a separate sheet) No

b.

What adjectives immediate come to mind in describing this applicant? ______________________________________

c.

Has the applicant ever violated an Honour Code or been placed on provation, suspended or expelled from your

institution?


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4.

CHECKLIST

Rate the applciant in the checklist below. We are interested in your comparison of the applicant to other university-bound

students at the same level in your university / institution.

No Basis for

Judgement

Marginal

(Lower 50%)

Average

(Top 50%)

Good

(Top 25%)

Excellent

(Top 10%)

Superior

(Top 3%)

Intellectual ability

Analytic frame of mind

Problem-solving orientation

Quality of oral expression

Sense of humour

Initiative

Intellectual Curiosity

Creativity

Motivation and Energy

Self-Confidence

Leadership / Influence

Integrity

Concern for others

Respect for differences

Warmth of personality

Ability to meet deadlineEmotion maturity

Reaction to setbacks

Respect accorded by faculty

Respect accorded by peers

If you wish to give reasons for any of your ratings, please attach additional sheets as required.

5.

SUMMARY

Based on your experience as Faculty Dean (for _________ years), how would you summarise the applicants promise as

compared to that of other university / institution bound students in your university?

Marginal(Lower 50%) Average(Top 50%) Good(Top 25%) Excellent(Top 10%) Superior(Top 3%)

Academic

Personal

Overall

Taking into account that the minimum eligibility requirement is 3 Grade A in GCE A Levels / 5 Mumtaz in STPUB, I

recommend this student for Univeriti Brunei Darussalam Chancellors Schoalrship.

Not at all With Reservation Fairly Strongly Strongly Enthusiastically


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CONFIDENTIAL

ATTACHMENT 3LECTURER / SUPERVISOR REFERENCE FORM

TO THE APPLICANT

Please fill in the personal information below and forward this form to your current or previous Lecturer / Supervisor who knows you

well and has taught or sueprvised you in an academic subject eitehr this year or the year before and is able to comment about y ou.

Each reference must be put in a sealed envelope, signed across the seal by the referee and returned to you by submission with your

scholarship application package.






TO THE LECTURER / SUPERVISOR





i. Description of the students intellectual and personal traits;

ii.

Abilities and achievemnts; andiii.

Possible information about personal circumstances that might have disadvantaged the applicant.

If you prefer to send a letter or statement (on the Universitys / Institutions letterhead and/or stamped), please feel free to do so.




Position ___________________________________ University / Institution _______________________________________________


Signature _________________________________ Date _______________________________________________

This report is based on (check all that apply): Personal contact with student Lecturers Observation

Records Others ____________________________________________________________________________________


In what capacity? ___________________________________________________________________________________________



In what subject(s) have you taught this applicant? _________________________________________________________________


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TRANSCRIPT Please include an official copy of the applicants transcript of work completed from the ir Undergraduate (or the




In what way might you distinguish this applicants academic performance from that of other qualified students? Please

comment on the students intellectual attitude, curiosity and enthusiasm for learning.

2. Through which of the following does this applicant achieve academic success? (Check all that apply)

Hard work / diligence Brilliance of mind Love of learning Other (Describe)

3.

PERSONAL / INTERPERSONAL

What do you like best about this student? In what ways has this student made an impact in your class, the school and/or in

the community? Are there any factors that might interfere with the students academic performance and/or personal

relationship during his/her couorse of study?

4. ADDITIONAL INFORMATION

d.

Is there anything else we should know about this applicant (e.g. personal circumstances, character, values, a point of



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5. CHECKLIST



No Basis for

Judgement

Marginal

(Lower 50%)

Average

(Top 50%)

Good

(Top 25%)

Excellent

(Top 10%)

Superior

(Top 3%)



Problem-solving orientationQuality of oral expression

Sense of humour

Initiative


Creativity


Self-Confidence


Integrity

Concern for others


Warmth of personalityAbility to meet deadline

Emotion maturity





6. SUMMARY

Based on your experience as Lecturer / Supervisor (for _________ years), how would you summarise the applicants promise

as compared to that of other university / institution bound students in your university?

Marginal

(Lower 50%)

Average

(Top 50%)

Good

(Top 25%)

Excellent

(Top 10%)

Superior

(Top 3%)

Academic

Personal

Overall





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CONFIDENTIAL

ATTACHMENT 4CLUB / ORGANISATION LEADER REFERENCE FORM

TO THE APPLICANT

Please fill in the personal information below and forward this form to a club / organisation leader who knows you well and is able to

comment about y ou. Each reference must be put in a sealed envelope, signed across the seal by the referee and returned to you by

submission with your scholarship application package.






TO THE CLUB / ORGANISATION LEADER





i.

Description of the students/members intellectual and personal traits;

ii. Abilities and achievemnts; and

iii.

Possible information about personal circumstances that might have disadvantaged the applicant.

If you prefer to send a letter or statement (on the organisation/universitys letterhead and/or stamped), please feel free to do so.




Position ___________________________________ Organisation _______________________________________________


Signature _________________________________ Date _______________________________________________

This report is based on (check all that apply): Personal contact with student Records

Others _________________________________________________________________________________________________


In what capacity? ___________________________________________________________________________________________




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TRANSCRIPT Please include an official copy of the applicants transcript of work completed from their Undergraduate (or the




In what way might you distinguish this applicants academic performance from that of other qualified students/members?

Please comment on the students intellectual attitude, curiosity and enthusiasm for learning.

2. Through which of the following does this applicant achieve academic success? (Check all that apply)

Hard work / diligence Brilliance of mind Love of learning Other (Describe)

3.

PERSONAL / INTERPERSONAL

What do you like best about this student/member? In what ways has this student/member made an impact in your club,

organisation and/or in the community? Are there any factors that might interfere with the students/members performance

and/or personal relationship during his/her couorse of study?

4. ADDITIONAL INFORMATION

e.

Is there anything else we should know about this applicant (e.g. personal circumstances, character, values, a point of



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5. CHECKLIST



No Basis for

Judgement

Marginal

(Lower 50%)

Average

(Top 50%)

Good

(Top 25%)

Excellent

(Top 10%)

Superior

(Top 3%)



Problem-solving orientationQuality of oral expression

Sense of humour

Initiative


Creativity


Self-Confidence


Integrity

Concern for others


Warmth of personalityAbility to meet deadline

Emotion maturity





6. SUMMARY

Based on your experience as Lecturer / Supervisor (for _________ years), how would you summarise the applicants promise

as compared to that of other university / institution bound students in your university?

Marginal

(Lower 50%)

Average

(Top 50%)

Good

(Top 25%)

Excellent

(Top 10%)

Superior

(Top 3%)

Academic

Personal

Overall





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CHECKLIST

Please check that you have enclosed the following application in your scholarship application package.

Completed application form (incomplete applications will not be processed).

2 recent passport size photographs of yourself.

Copy of IC.

Copy of Passport

Certified true copies of Transcripts / Certificiates (e.g. GCE A Level Examination result slips)

TOEFL / IELTS, SAT I and SAT II Scores (If not yet sat for, please provide date of candidature).

Co-curricular Activities (CCA) reports / certificates

Attachment 1Application Essay.

Attachment 2Faculty Dean Reference Report.

Attachment 3Lecturer / Supervisor Reference

Attachment 4Club / Organisation Leader Reference Report.

Copies of any other supporting documents (certified true copies, where relevant)

REMINDER

It is your responsibility to ensure that all application material is sent in time

to the Scholarship Office, Universiti Brunei Darussalam by the application

deadline. Early application is encouraged.

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