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THE CHINESE CHAMBER OF COMMERCE AND INDUSTRY

OF KUALA LUMPUR AND SELANGOR

(APPLICATION FORM FOR UNIVERSITY / COLLEGE SCHOLARSHIP FUND)

Please the fund that you apply

SCHOLARSHIP

LOAN

PARTICULARS OF APPLICANT (Please write in CAPITAL LETTER / TYPE )

As printed in I. C.
( Chinese) :

New I. C. No. :

( English) :

Permanent Address :

House Tel No. :

Correspondence Address :

H/P No. :

Date of Birth :

Place of Birth :

Nationality :

Age :

Sex :

E-mail :

EDUCATION QUALIFICATION

From

Name of School or College

Year
To

Primary Education

Chinese

Malay

Examinations Passed

Other

PARTICULARS OF APPLICANTS FAMILY

Name of Father :
(Chinese & English)

Age : New I. C. No. :

Occupation &
Income :

Name of Mother :
(Chinese & English)

Age : New I. C. No. :

Occupation &
Income :

Name of Guardian :
(Chinese & English)

Age : New I. C. No. :

Occupation &
Income :

Please list your brothers and sisters who are schooling and working

Name

Relationship
Age

/
Occupation / Schooling

1.
2.
3.
4.
Total Family Income RM_______________________

Monthly Income (RM)


Name and Address of University or College the applicant enrolled in or at present studying.

Faculty __________________________

Course ____________________________

2013 7 1
Year (As at 1/7/2013) ___________________

Year of Graduation _________________________

____________________________

Did the applicant ever receive KLSCCCI Scholarship?

No
Yes, Amount __________________ Year_______________

Did the applicant receive any other scholarship or study loan from other organisations for his / her education?
If yes, please give particulars.

Name :

Amount & Year :

( APPLICABLE TO LOAN ONLY)

RM ________________ _________ _________ ________
Requested loan sum per annum : RM__________________From________To________, Total_______Years.
(Year)
(Year)

Estimated expenses per annum : RM _______________________

Please give names, I. C. No., occupation and addresses of two guarantors (Excluding parents of applicant) :
()
Name (Chinese & English)

New I. C. No.

Occupation, Company Name,

Add

Address, Tel No.

1.

2.

_________________
I, ___________________ hereby declare that the above particulars are true and correct. If any of the above
particulars are found to be untrue or incorrect, I agree to accept any action brought against me by the
Chamber.

Signature of Applicant
(As at 08-04-13)

/
Signature of Parent / Guardian

Date
C7-11-13/CSW