KUOK FOUNDATION BERHAD

Tingkat 14 Wisma Jerneh, 38 Jalan Sultan Ismail, 50250 Kuala Lumpur Tel: 03 - 2142 5319 E-mail: general@kuokfoundation.com Website: www.kuokfoundation.com
(9641-T)

Borang permohonan untuk bantuan kewangan pelajaran Application form for educational assistance ARAHAN INSTRUCTIONS
Taip atau tulis dengan jelas. Gunakan HURUF BESAR. Please type or write clearly. Please use BLOCK LETTERS. Taip atau tulis nama penuh anda sepertimana yang terdapat dalam kad pengenalan anda. Gariskan nama keluarga anda. Type or write your name in full as it appears in your NRIC and underline your surname. Sekiranya ruang menulis tidak mencukupi, gunakan kertas tambahan dan lampirkan bersama borang permohonan. If space is insucient, please continue in a separate sheet and attach the sheet to the application form. Salinan dokumen yang berkaitan yang telah disahkan mestilah dilampirkan. (Sila rujuk Syarat Permohonan yang dilampirkan). Certied copies of relevant documents must be attached. (Please see Conditions and Procedures for Application attached). Tarikh tutup permohonan: Closing date for application:
Gambar TERBARU Pemohon RECENT Photograph of Applicant

Nama pemohon seperti kad pengenalan Name of applicant as in NRIC

MAKLUMAT PEMOHON / PARTICULARS OF APPLICANT

No. kad pengenalan NRIC number Lelaki Male Perempuan Taraf perkahwinan Marital status Female

Alamat rumah (Tetap) Home address (Permanent)

Alamat surat-menyurat Postal address

Bandar dan Negeri City and State No. telefon rumah Home telephone no. Tarikh dan tempat lahir Date and place of birth Kedudukan sekarang pada masa pemohonan Present status at time of application

Poskod Postal code No. telefon bimbit Handphone no.

Bandar dan Negeri City and State Alamat e-mail E-mail address Umur Age Kewarganegaraan Citizenship Bekerja tetap Full-time employment

Poskod Postal code

Bangsa Race Bekerja sementara Part-time employment

Menuntut sepenuh masa Studying full-time

FOR OFFICE USE ONLY

RECEIVED: REMARKS: REF. NO.:

BUTIR-BUTIR KURSUS / COURSE DETAILS

Lokasi institusi Location of institution Mula kursus Commencement of course (mm/yyyy) Tamat kursus Completion of course (mm/yyyy)

Kursus dipohon (pilihan pertama) / Sedang dituntut Course applied (first choice) / Attending Nama institusi Name of institution Jangkamasa kursus Duration of course

Butir - butir perbelanjaan diperlukan setahun (nyatakan dalam Ringgit Malaysia) Breakdown of estimated expenses required per annum (in Malaysian Ringgit) Yuran kursus Tuition fees Yuran lain Other fees Tempat tinggal Accomodation Makanan Food Perbelanjaan lain Other expenditure Jumlah Total Bilangan tahun bantuan diperlukan No. of years assistance required

Sumbangan setahun daripada keluarga / sumber lain. Nyatakan sumber Amount per annum which can be obtained from family / other sources. State sources

Jumlah bantuan dipohon setahun Amount applied for per annum

MAKLUMAT KELUARGA / INFORMATION ON FAMILY

Nama ibu Mothers name Umur Age No. kad pengenalan NRIC number Alamat Address Umur Age

Nama bapa / penjaga Father / Guardians name No. kad pengenalan NRIC number Alamat Address

Bandar dan Negeri City and State No. telefon rumah Home telephone no. Pekerjaan Occupation
Kerja sepenuh masa Full-time employment

Poskod Postal code No. telefon bimbit Handphone no. Pendapatan kasar sebulan Gross monthly income
Kerja separuh masa Part-time employment Perniagaan sendiri Own business Bersara Retired

Bandar dan Negeri City and State No. telefon rumah Home telephone no. Pekerjaan Occupation
Kerja sepenuh masa Full-time employment

Poskod Postal code No. telefon bimbit Handphone no. Pendapatan kasar sebulan Gross monthly income
Kerja separuh masa Part-time employment Perniagaan sendiri Own business Bersara Retired

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.

No. telefon pejabat Office telephone no. Butir - butir SEMUA adik-beradik (kecuali pemohon) Particulars of ALL brothers and sisters (exclude applicant) Nama Name Jantina Umur Taraf Gender Age perkahwinan Marital status Bil. anak (jika ada) No. of children (if any)

No. telefon pejabat Office telephone no.

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 sebulan Gross monthly income

MAKLUMAT PENDIDIKAN / INFORMATION ON EDUCATION

Bandar dan Negeri City and State Tahun mula Tahun tamat Keputusan yang dicapai Year commenced Year completed Qualifications obtained

Butir-butir sekolah pemohon pernah belajar Details of schools previously attended by applicant Nama sekolah School name

KEPUTUSAN PEPERIKSAAN / EXAMINATION RESULTS

Tahun Year Gred Grade STPM / A level / Matrikulasi atau kelayakan yang setaraf dengannya Tahun STPM / A level / Matriculation or equivalent Year Mata pelajaran Subject Gred Grade

SPM /SPVM / O level atau kelayakan yang setaraf dengannya SPM / SPVM / O level or equivalent Mata pelajaran Subject

Keputusan peperiksaan universiti / kolej / politeknik seperti gred keseluruhan / purata nilai gred kumulatif, jika ada University / college / polytechnic examination results such as overall grades / cumulative grade point average, if applicable Tahun pertama First year Tahun kedua Second year Tahun ketiga Third year Tahun keempat Fourth year

PENCAPAIAN KO-KURIKULUM / CO-CURRICULAR ACHIEVEMENTS

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

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

BANTUAN KEWANGAN / FINANCIAL ASSISTANCE

Jumlah setahun Amount per annum

Butir-butir bantuan termasuk pinjaman yang anda terima terdahulu dan sekarang, jika ada, oleh organisasi-organisasi atau sumber-sumber lain Details of past and present assistance including loans, if any, received from other organisations or other sources Tahun diterima Pinjaman atau biasiswa Nama organisasi / sumber lain Name of organisation / other sources Year received Loan or scholarship

Namakan organisasi lain yang anda pernah memohon biasiswa / pinjaman Name 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 permohonan Year of application Nombor rujukan, jika ada Reference number, if any Ada Yes Tidak No

Jumlah bantuan diterima, jika ada Amount of assistance received, if any Ada Yes Tidak No

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-beradik If yes, state name of brother / sister 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-beradik If yes, state name of brother / sister

Tahun, jenis bantuan atau nombor rujukan kami Year assisted, type of award or our reference number Ada Yes Tidak No

Institusi sedang dituntut / dipohon Institution attending / applied to

MAKLUMAT PERUJUK / INFORMATION OF REFEREES

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 applicants family for a period of not less than 3 years. Referees can be relatives or close family friends BUT not applicants own parents, brothers / sisters or fellow students. Referees should be contactable by telephone during office hours. Nama (Encik / Cik / Puan) Name (Mr / Miss / Mrs / Madam) Alamat Address Nama (Encik / Cik / Puan) Name (Mr / Miss / Mrs / Madam) Alamat Address

Bandar dan Negeri City and State No. telefon rumah Home telephone no. Pekerjaan Occupation Jumlah tahun mengenali pemohon No. of years known

Poskod Postal code No. telefon bimbit Handphone no. No. telefon pejabat Office telephone no. Pertalian dengan pemohon Relationship to applicant

Bandar dan Negeri City and State No. telefon rumah Home telephone no. Pekerjaan Occupation Jumlah tahun mengenali pemohon No. of years known

Poskod Postal code No. telefon bimbit Handphone no. No. telefon pejabat Office telephone no. Pertalian dengan pemohon Relationship to applicant

LAIN-LAIN MAKLUMAT / OTHER INFORMATION

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 permohonan Date of application

Tandatangan pemohon Applicants signature

KUOK FOUNDATION EDUCATIONAL ASSISTANCE DATA FORM

PLEASE FILL IN SECTIONS I, II, III, IV, V & VI ONLY FOR OFFICE USE RACE SEX
*F/M APPLICANTS REF. NO. FINANCIAL STATUS TY: YPH: REMARKS
No. of children Ranking in family No. studying Father or : Age Guardian : Occ : GY Mother : Age : Occ : GY -

BL

CR KIV

I II

NAME OF APPLICANT PARTICULARS OF COURSE

FS:

1. Name of Course
* Applied / Attending

2. Name of *University / College / Polytechnic 3. Course Year (in the coming academic session)

III EXAMINATION RESULTS (Do not write on shaded boxes)

1. *SPM / SPVM / O Level results 1A 2A A+ A A3B 4B 5C 6C Year B3 B4 B5 B6 C7 C8 B+ B C+ C Year 7D 8E 9G D E G

Siblings GY

2. UEC results A1 A2

UEC refers to Unified Examination Certificate for Independent Chinese Secondary Schools in Malaysia.

3. *STPM / A Level results A B C A AB+ B D E

Year BC+ C CD+ D

4. Matriculation results *CGPA / Overall Grade

Year

5. MUET results Band Year

6. Latest *University / College / Polytechnic results *CGPA / Overall Grade

IV HAVE YOU PREVIOUSLY APPLIED TO KF?

If yes, please state year applied :

*YES / NO

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. 2. 3. 4. 5. 6. 7. 8. 9.

University / College / Polytechnic acceptance letter Parents / Guardians proof of income for the past 2 years Brothers and sisters proof of income for the past 2 years, if they are working Letters or documents to prove that brothers and sisters are pursuing higher education in universities / colleges / institutions University / College / Polytechnic results (Actual/Forecast) STPM / A Level / Matriculation / Foundation (Actual/Forecast) & MUET results SPM / SPVM / O Level / UEC results (Actual/Forecast) Identity card and birth certificate of applicant Birth certificates of all brothers and sisters

10. Parents / Guardians 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 Foundations 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 Bahasa Melayu Bahasa Inggeris Pendidikan Moral Sejarah Mathematics Additional Mathematics Physics Chemistry Biology Bahasa Cina English for Science and Technology A+ AB AB C+ B+ B+ B+ C+ A TO COMPLETE IN THIS MANNER 1. *SPM / SPVM / O Level results 1A 2A A+ A A1 1 2 3B 4B 5C 6C B+ B C+ C 3 2 2 Year 7D 8E 9G 2009 D E G

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.