2015 DR GOH KENG SWEE (GKS) SCHO

INSTRUCTIONS TO APPLICANT

1. There are 3 parts in this application you must complete Form, Essay and Declaration & Survey. All parts m
the "Yes, I agree" option, to agree to the clause under Declaration.
2. Please note the following, in completing your application form:
Fields indicated with (*) are compulsory and must be completed.
All other fields should be entered if the relevant information is available.
Indicate 'Nil' if fields are not applicable.
Refer to the tab Sample Form for a sample of a completed form.
Do not add, delete or format any cells in the form.

3. Email completed applications (Form, Essay and Declaration & Survey) to applications@psd.gov.sg, by 23 Feb
applications and applications received after this date will not be considered.

4. Photocopies of your birth certificate/passport and educational certificates must be produced for verification pu
5. You should have taken, or have registered to take the SAT. It is important to concurrently apply for admission
guidelines and deadlines.
6. Shortlisted candidates will have to attend an interview in Singapore in mid-May 2015.

Personal and Family Particulars

Name in CAPS*
Date of Birth (DD/MM/YYYY)*
Citizenship*
Identification/Passport no.*

Family Background
Father
Father's name*
Citizenship*
Occupation*
Company name*
Mother
Mother's name*
Citizenship*
Occupation*
Company name*

Siblings
Name
Relationship Select an option
Citizenship
Occupation
Company/school

Name
Relationship Select an option
Citizenship
Occupation
Company/school

Name
Relationship Select an option
Citizenship
Occupation
Company/school
Name
Relationship Select an option
Citizenship
Occupation
Company/school
Currently studying in Singapore under a scholarship?

Select an option
If "Yes", indicate name of scholarship

Additional information
Country of birth*
Religion*
Ethnic Group*
Marital Status* Select an option
Gender* Select an option
Postal Address (line 1)*
Postal Address (line 2)
Postal Address (line 3)
Contact number 1*
Contact number 2
Contact number 3

Personal and Family Particulars

Email Address*

Academic Results

Name of Pre-University Institution*

Qualification Obtained*
(eg. GCE 'A' Level,
International Baccalaureate)
Subject*
(list all subjects taken in final exam and grades obtained)

Grade*

Are the above results your final results?* Select an option

If "No", please indicate expected date of
receiving your final results:
MM/YYYY
SAT Scores
Note: 1. Enter scores from best attempt; do not combine scores from different sittings.
2. If your SAT scores are not available yet, or if you are expecting a new set of results, you may email them to
application@psd.gov.sg before application closes.
National
(1) SAT*
Score*
Percentile*
Reading
Math
Writing
Total
0
(2) SAT Subject Tests (optional)
Subject

Score

National
Percentile

Notable Achievements
Prizes / Awards / Co-Curricular Activities

Year

Note: Please include any significant academic and non-academic achievements, including leadership positions held, major
competitions won or participated in, awards won, and significant contributions in community service and volunteering work.
(eg. Bronze Medalist in International Physics Olympiad/ President of High School Photographic Society, Student Leader for
Disabled Children's Camp 2012.)

Academic Results

University Application
Singapore Universities
1st choice*

Name of university National University of Singapore

Course of study
Status of application Select an option

Single/double degree

Option

Name of university Select an option

Course of study
Status of application Select an option

Single/double degree

Option

Name of university Select an option

Course of study
Status of application Select an option

Single/double degree

Option

Name of university Select an option

Course of study
Status of application Select an option

Single/double degree

Option

Name of university Select an option

Course of study
Status of application Select an option

Single/double degree

Option

Name of university
Course of study
Status of application Select an option

Single/double degree

Option

Name of university
Course of study
Status of application Select an option

Single/double degree

Option

Name of university
Course of study
Status of application Select an option

Single/double degree

2nd choice

3rd choice

4th choice

5th choice

Overseas Universities

Application for Other Scholarship(s)

Name of Organisation
Scholarship type Select an option
Course of study
Status of application Select an option
Name of Organisation
Scholarship type Select an option
Course of study
Status of application Select an option
Name of Organisation
Scholarship type Select an option
Course of study
Status of application Select an option

University Application

In no more than 500 words, describe an experience or incident that has shaped your values.
How did this experience or incident affect you? How did you change as a result of this experience or incident?
(Press Alt+Enter to move to a new line within the field.)
Type your essay here.

Do you hold any citizenship, other than the one entered in the "Form" section?

Select an option

If "Yes", pls state country of citizenship below:

Do you hold Permanent Residence Status of any other country?

Select an option

If "Yes", pls state country of Permanent Residence Status below:

Have you ever suffered, or are you suffering from any physical impairment, disease or mental illness?

Select an option

If "Yes", pls state details of condition below:

Have you ever been convicted in a court of law in any country?

Select an option

If "Yes", pls state details below:

Have you previously applied for the Dr. Goh Keng Swee Scholarships?

Select an option

If "Yes", pls state previous year(s) of application below:

Have you studied in Singapore before?

Select an option

If 'Yes', please indicate period of study and the school which you studied in below:

By submitting this form to the Dr. Goh Keng Swee Scholarship Fund, I declare that the information provided in this application is correct.
I declare that the information in all parts of this form are true to the best of my knowledge, and I have not wilfully suppressed any material facts.
I understand that any provision of inaccurate or false information or omission of information will render my application invalid and that, if admitted on the
basis of such information, I will be required to withdraw from the scholarship.

Select an option

Survey
Thank you for you interest in the Dr Goh Keng Swee scholarship.
To help us in our review and publicity efforts, please let us know where you have obtained information on the Dr Goh Keng Swee Scholarship.

Please let us know if you have any other feedback or comments on the application exercise below.

Form

Fields indicated with (*) are compulsory

Personal and Family Particulars

Name in CAPS*
Date of Birth (DD/MM/YYYY)*
Citizenship*
Identification/Passport no.*

Alyssa Kristiano
9/14/1993
Indonesia Citizen
123456789X

Family Background
Father
Father's name*
Citizenship*
Occupation*
Company name*

Arthur Kristiano
Indonesia Citizen
Author
N.A.

Mother's name*
Citizenship*
Occupation*
Company name*

Athena Wijaja
Indonesia Citizen
Homemaker
N.A.

Name
Relationship
Citizenship
Occupation
Company/school

Alexander Kristiano
Brother
Indonesia Citizen
Student
Excelpro High School

Name
Relationship
Citizenship
Occupation
Company/school

Amelia Kristiano
Sister
Indonesia Citizen
Student
Excelpro High School

Name
Relationship
Citizenship
Occupation
Company/school

Angelina Kristiano
Sister
Indonesia Citizen
Student
Glory Junior School

Mother

Siblings

Name
Relationship
Citizenship
Occupation
Company/school

Currently studying in Singapore under a scholarship?

Yes
If "Yes", indicate name of
scholarship

Additional information
Country of birth*
Religion*
Ethnic Group*
Marital Status*
Gender*
Postal Address (line 1)*
Postal Address (line 2)
Postal Address (line 3)
Contact number 1*
Contact number 2
Contact number 3
Email Address*

MOE ASEAN Scholarship

Indonesia
Islam
Malay
Single
Female
123 Elite Park
1234 Jakarta, Indonesia
062 - 21 - 81 1234 1234

alyk@gmail.com

Academic Results
Excelpro High School
Name of Pre-University Institution*
Qualification Obtained*
(eg. GCE 'A' Level,
International Baccalaureate)

Surat Tamat Sekolah Menengah Umum Tingkat Atas

Subject*
(list all subjects taken in final exam and grades obtained)
English
Indonesian Language
Mathematics
Physics
Chemistry
History
Sociology
Arts

Are the above results your final results?*

If "No", please indicate expected date of
receiving your final results:
SAT Scores

Note: 1. Enter scores from best attempt; do not combine scores from different sittings.
2. If your SAT scores are not available yet, or if you are expecting a new set of results, you may email them to application@
application closes.
(1) SAT*
Reading
Math
Writing
Total
(2) SAT Subject Tests (optional)
Subject

Score*
790
720
770
2280

Score

Notable Achievements
Prizes / Awards / Co-Curricular Activities
National Mathematics Challenge 2013 Runner-up
Excelpro High School Nature Appreciation Club President
Co-organised Project Samaritan (an event to distribute collected donations to the homeless)
Volunteer of the Month - nominated for community service
Contributions at Milendra Family Service Centre

Note: Please include any significant academic and non-academic achievements, including leadership positions held, major
participated in, awards won, and significant contributions in community service and volunteering work.

(eg. Bronze Medalist in International Physics Olympiad/ President of High School Photographic Society, Student Leader for
Camp 2012.)

University Application
Start Year*
End Year*

2010
-2015

Year of exam*

2015

Grade*
A
A
B
A
A
B
B
C

Singapore Universities
1st choice*

Name of university
Course of study
Status of application
2nd choice
Name of university
Course of study
Status of application
3rd choice
Name of university
Course of study
Status of application
4th choice
Name of university
Course of study
Status of application
5th choice

No

Name of university
Course of study
Status of application

03/2015
Overseas Universities

ail them to application@psd.gov.sg before

790
720
770
2280

National
Percentile*
86
79
89

National
Percentile

Name of university
Course of study
Status of application
Name of university
Course of study
Status of application
Name of university
Course of study
Status of application

Application for Other Scholarship(s)

Year
2013
2011-2012
2011
2009, 20102011
Dec 2010

hip positions held, major competitions won or

rk.

ciety, Student Leader for Disabled Children's

Name of Organisation
Scholarship type
Course of study
Status of application
Name of Organisation
Scholarship type
Course of study
Status of application
Name of Organisation
Scholarship type
Course of study
Status of application

ation

es
National University of Singapore
Business Administration
Pending University's Reply

Single/double degree

Single Degree

Nanyang Technological University

Business Administration
Select an option

Single/double degree

Single Degree

Singapore Management University

Engineering and Management Science
Select an option

Single/double degree

Double Degree

Single/double degree

Option

Single/double degree

Option

Single/double degree

Single Degree

Single/double degree

Option

Select an option
Select an option

Select an option
Select an option

University of Cambridge
Economics
Pending Applicant's Acceptance of Offer

Select an option

Single/double degree
Select an option

r Scholarship(s)

National University of Singapore

Local Scholarship
Economics
Pending Organisation's Reply

Select an option
Select an option

Select an option
Select an option

Declaration

Please answer all the questions below. Provide further details if "Yes" is selected for any of t

By submitting this form to the Dr. Goh Keng Swee Scholarship Fund, I declare that the information provided
I declare that the information in all parts of this form are true to the best of my knowledge, and I have not wilfully
I understand that any provision of inaccurate or false information or omission of information will render my applicati
basis of such information, I will be required to withdraw from the scholarship.

Yes, I agree.

Survey

Thank you for you interest in the Dr Goh Keng Swee scholarship.
To help us in our review and publicity efforts, please let us know where you have obtained information on the D

I heard about the scholarships from my school and googled for the Dr. Goh Keng Swee scholarsh
Please let us know if you have any other feedback or comments on the application exerc
None. Thank you

Declaration

Please answer all the questions below. Provide further details if "Yes" is selected for any of the quest
Do you hold any citizenship, other than the one entered in the "Form" section?
If "Yes", pls state country of citizenship below:
Do you hold Permanent Residence Status of any other country?
If "Yes", pls state country of Permanent Residence Status below:
Have you ever suffered, or are you suffering from any physical impairment, disease or mental illness?
If "Yes", pls state details of condition below:
Have you ever been convicted in a court of law in any country?
If "Yes", pls state details below:
Have you previously applied for the Dr. Goh Keng Swee Scholarships?
If "Yes", pls state previous year(s) of application below:
Have you studied in Singapore before?
If 'Yes', please indicate period of study and the school which you studied in below:
2002 - 2003, Anglo Chinese School (Junior)

By submitting this form to the Dr. Goh Keng Swee Scholarship Fund, I declare that the information provided in this ap
I declare that the information in all parts of this form are true to the best of my knowledge, and I have not wilfully suppres
I understand that any provision of inaccurate or false information or omission of information will render my application invalid
basis of such information, I will be required to withdraw from the scholarship.

Yes, I agree.

Survey

Thank you for you interest in the Dr Goh Keng Swee scholarship.
To help us in our review and publicity efforts, please let us know where you have obtained information on the Dr Goh Ke

I heard about the scholarships from my school and googled for the Dr. Goh Keng Swee scholarship websit
Please let us know if you have any other feedback or comments on the application exercise below
None. Thank you

ons.
No

No

No

No

No

Yes

plication is correct.
sed any material facts.
d and that, if admitted on the

eng Swee Scholarship.

e.
.