TITIJAYA

Recent passport-
SCHOLARSHIP size photograph
of applicant
FUND
PARTA:PARTICULAROFAPPLICANT
Name(asperNRIC):
IdentityCardNumber: Age: Gender:
DateofBirth: Citizenship:
HomeAddress:

CorrespondenceAddress(ifdifferentfromtheabove):

emailaddress:
ContactNo(residence): MobileNo:
st
1 YearStudent 2ndYearandAboveStudent
Present StudentIDNo.:
Status Ifnotfirstyearstudent,pleasestateyearofcourseincomingsession:

Ifcurrentlyemployed(permenantortemporary),pleasestateoccupation:

Noofmonths/yearsinemployment:
Lastdrawnsalarypermonth:
Is/Areyourparentemployee(s)ofTitijayaGroupofCompanies Yes No
Ifyes,pleasestatenameoftheperson:

PARTB:PARTICULAROFCOURSEPURSUING
Courseattending:
NameofUniversity:
Location:
DateofCommencement: Duration:
Amountperannumwhichcanbeobtainfromfamily/othersources(inRM)

*pleaseenclosetheacceptanceletterfromtherelevantuniversity
PARTC:FAMILYPARTICULARS
Parents
NameofFather/Gurdian*: Age:
IdentityCardNo: ContactNo:
Occupation: NameofEmployer:
Salary/Income/Pension(RMpermonth):
*deleteaccordingly

NameofMother/Gurdian*: Age:
IdentityCardNo: ContactNo:
Occupation: NameofEmployer:
Salary/Income/Pension(RMpermonth):
*deleteaccordingly

Siblings(excludedapplicant)
Name Relationship Age Occupation GrossIncome
1)
2)
3)
4)
5)
6)
7)
8)

DoyouhaveasiblingwhoiscurrentlyorwaspreviouslyarecipientoftheTITIJAYAscholarship?
Ifyes,pleaseprovidesibling'sname:
No

PARTD:LANGUAGES
Languages Speak Write Read
1)
2)
3)
4)
5)
PARTE:EDUCATIONBACKGROUND
SchoolsAttended From To Result
1)
2)
3)
4)
5)
*pleaseencloseacopyofSPM,SPM(V),STPM,ALevelresult

Ifyouareasecondyearorabovestudent,pleasefillintheoverallgrade.
FirstYear SecondYear ThirdYear

*pleaseencloseacopyofuniversityexaminationresultslip

PARTF:EXTRACURRICULARACTIVITIES
Society/Club/OtherActivities From To HighestPositionHeld
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
*pleaseencloseacopyofcertificate,testimonials

TypeofSports/Games Year Level Representing

1)
2)
3)
4)
5)
6)
*pleaseencloseacopyofcertificate,testimonials
PARTG:REFEREES
 1)Name: NRIC:
ContactNo: Occupation
Relationship: YearsKnown:

2)Name: NRIC:
ContactNo: Occupation
Relationship: YearsKnown:
*PleasedonotselectmembersofthefamilyorrelativesasReferees

PARTH:PERSONALMOTIVATION/OBJECTIVES

*Innotmorethan200words,tellusaboutyourpersonalmotivation/careeraspiration
PARTI:OTHERINFORMATION&DECLARATION
 Pleasestateotherrelevantinformationtosupportyourapplicationexpenses.

Itheundersigned,declarethattheinformationgivenbymeinthisformistruetothebestofmy
knowledgeandthatIhavenotwillfullysuppressesanymaterialfactrelevanttothisapplication.
Ihavereadandagreedtobeabidebythetermsandconditionsofthescholarship/financialassistance.
Iunderstandthatthescholarshiphereincanbewithdrawnatanytimeifanyinformationgiveninthis
foundtobeincorrect.Ihavereadandunderstoodtheconditionsoftheawardsasstatedinthe
applicationformandtheattachedTermsandConditions.

ApplicantsSignature Date

PARTJ:DOCUMENTCHECKLIST
Haveyouenclosedcertifiedcopiesof Yes No

1.Universityacceptanceletter
2.Parents/Guardiansproofofincomeforthepast2years
3.Brothersandsistersproofofincomeforthepast2years,iftheyareworking
4.Lettersordocumentstoprovethatbrothersandsistersarepursuinghigher
educationinuniversities/colleges/institutions
5.Identitycardandbirthcertificateofapplicant
6.Birthcertificatesofallbrothersandsisters
7.Parents/Guardiansidentitycards
8.SPM/SPVM/OLevelresults
9.STPM/ALevel/Matriculationresults
10.University/College/Polytechnicresults
11.Schooltestimonials
12.Schoolleavingcertificates

*pleasetick()eitherYesorNo.

FOROFFICEUSEONLY
PreliminarySelection

Shortlisted K.I.V Rejected

Checkedby Verifiedby
Date: Date:

InterviewedbyScholarshipCommitteeon__________________bythefollowing:
(1)_______________________(2)________________________(3)________________________

Accepted K.I.V Rejected

Recommendation:

ApprovedforscholarshiponbehalfofTITIJAYASCHOLARSHIPFUND

Approvedby Date

HomeVisitConductedon________________by:

(1)_______________________(2)________________________(3)________________________

MentorAssigned:

Name:____________________________Company/Division:________________________