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PIDM UNDERGRADUATE SCHOLARSHIP PROGRAMMEAPPLICATION 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 certied ‘true copies as per theoriginal documents by the rele!ant authorities.

". All elds in the form must be lled up properly and clearly and must not be leftblan#. $tate %&ot Applicable' or %‘&A' for areas that that are not applicable toyou.

(. Ensure your application is for courses at the public and)or pri!ate uni!ersitiesand)or colleges appro!ed by P*+, only- for which you ha!e gained acceptanceto.

. Please send the duly completed form with all the required supporting

documents latest by18 April 2016 to:/

Human Capial Di!i"i#n$S%lar"&ip Pr#'ramm()P(r*a+anan In"uran" D(p#"i Mala,"iaL(!(l 12- A.iaa T#/(r $#rm(rl, n#/n a" uill 3)N#45 alan S("(n S(nral 7uala Lumpur S(nral-70930 uala Lumpur

0r email your application to &%:pi+m4'#!4m,

SECTIONA

PERSONAL DETAILS

&ame as per&*

:

esidentialAddress

:

:

3ouse 4el. &o. : ,obile &o. :

&* &o. : Email Address :

&ationality : 5ender :

+ate of 6irth :

SECTION;

UNI

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1. 1.

2. 2.

3. 3.

SECTIONC

EDUCATIONAL UALIFICATION=E>TRA CURRICULARACTI

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NO

SU;ECT GRADE NO

SU;ECT GRADE

1. 9.

2. ;.

".

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&* &o. : &* &o. :

0ccupation : 0ccupation :

&ame of

Employer

: &ame of

Employer

:

Address ofEmployer

: Address ofEmployer

:

+ate $tart : +ate $tart :

0?ce 4el. &o. : 0?ce 4el. &o. :

,obile &o. : ,obile &o. :

SUMMAR OF INCOME

@Please attach rele!ant documents- i.e. salary slip- statement of income- where applicable

Imm(+ia( Famil, M(m*(r" Gr#"" In%#m( P(r M#n& $RM)

1

.>egal 5uardian- where applicable

2. 7ather

(. ,other

.

Applicant

0ther sources of income eg. ental- etc Bplease specifyC

1.

2.

".

TOTAL

O&(r In#rmai#nB $Pl(a"( i% a &( appr#pria( %#lumn an+ pr#!i+( &( in#rmai#na%%#r+in'l,)

 1. urrent residence: 0wned- fully paid 0wned- under mortgaged: ,onthlyinstalment ,DDDDDDDD 

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  ented: ,onthly rental ,DDDDDDDDDDD 

2. 4ype of esidence BPlease specifyC: DDDDDDDDDDDDDDDDDDDDD Beg. bungalow)$emi/+)terrace

house)condominium) at etcC.

". +o your parents)legal guardian own any lands ) houses ) shoplots or other immo!able assetsF es &o

aC *f yes- please state the type and estimated !alue : 4ype : DDDDDDDDDDDDDDDDDDDDDDD Galue : , DDDDDDDDDDDDD 

(. +o your parents)legal guardian ha!e any shares- unit trusts or other in!estmentsF es&o

aC *f yes- please state the type and estimated !alue : 4ype : DDDDDDDDDDDDDDDDDDDDDDD Galue : , DDDDDDDDDDDDD 

. 3ow many of your siblings Bif anyC contribute to the household incomeF DDDDDDDDDDDDDDDDDDDDD 

9. 4otal monthly contribution from siblings is , DDDDDDDDDDDDDDDDD 

NAMES AND PARTICULARS OF SI;LINGS

Pl(a"( u"( "(para( "&(( i n(%(""ar,

N#

Nam( A'(

Pl(a"( "a(#%%upai#n #r i 

"ill "u+,in'

Nam( # S%#l=C#ll('(=Uni!(r"i

,= Empl#,(r

Pl(a"( "a(i &(

p(r"#n i" inr(%(ip # aS%lar"&ip

r#m an,Or'ani"ai#

n

Gr#""In%#m(

P(r M#n&$RM)

1.

2.

".

(.

.

9.

;.

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oanF *f es- please furnish

details:

 es B C &o B C

SECTIONF

E

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3ow did you nd out about P*+, $cholarship programmeF Please tic# at the appropriate boHes.

$ocial Engine : 5oogle 6ing

$ocial ,edia : 7aceboo# 4witter

&ewspaper Ad!ertisement: 4he $tar ,etro 4he $unPen. ,alaysia:

East ,alaysia: 6orneo Post &ew $abah 4imesItusan $arawa#

0thers: 7riends 7amily )elati!es0thers: DDDDDDDDDDDDDDDD  Bplease stateC 

P*+, $cholars )Alumni : DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD   Bplease state thenameC

 

SECTIONG

ESSA 

Please submit a written essay in English of approHimately 1888 words on your chosen eld andyour aspirations in contributing to the nancial ser!ices landscape and the country in general.@Please use separate sheets of papers if the column pro!ided is not su?cient

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number and details of your request. 

*- DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD- *) &o. DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD do

hereby certify that all information pro!ided in this application are true and accurate to the best

of my #nowledge and ha!e not withheld any material information which might inuence the

consideration of this application. * understand that any

misrepresentation)false declaration or omission will result in cancellation or withdrawal of any

scholarship awarded.

* also authorise any in!estigation of the abo!e information for the purposes of !erication. *

conrm that * ha!e obtained the consent of my parentBsC- legal guardianBsC- siblingsBsC-

refereeBsC and)or other third parties to disclose their personal data as requested in this form.

 DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD DDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDDD 

Applicants $ignature +ate

CHECLIST

Please ensure all the documents listed below are included in your scholarship applicationsubmission:/

ompleted application formertied true copy of &ational egistration *dentication ard B6oth $ides on

A( paperC

ertied true copy of $iKil PelaKaran ,alaysia and other higher educationtranscript

ertied true copy of applicants)parents)guardians most recent EA)6E7orm)Payslips

 4aH eturn 7orm )any other proof of income

1888 word essay

ecent passport/siLed colour photographAcceptance)0Mer >etter by Ini!ersity or pri!ate college to underta#e a eld ofstudy as appro!ed by P*+,

P*+, accepts documents that are certied by any of the following indi!idual:/

1. 5rade A 5o!ernment 0?cer

2. $chool Principal)3eadmaster

". ommissioner of 0ath

(. %Netua Nampung'. %Ahli Oawatan#uasa NemaKuan dan Neselamatan Nampung'

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9. 4he employer or authorised representati!e of the employer

FOR OFFICE USE ONL 

+ate Application ecei!ed ecei!ed by

:

$hortlisted for inter!iew es &o

omments:/

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