pidm_saf2010

PIDM 2013 SCHOLARSHIP AWARD APPLICATION FORMPlease 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 certified true copies as per the original documents by the relevant authorities.3. All fields in the form must be filled up properly and clearly and must not be left blank. State Not Applicable or NA for areas that that are not applicable to you.4. Ensure your application is for courses at the public and/or private universities and/or colleges approved by PIDM only, for which you have gained acceptance to.

5. Please send the duly completed form with all the required supporting documents latest by 26 April 2013 to:-

Human Capital Division(Scholarship Programme)

Perbadanan Insurans Deposit Malaysia

Level 12, Quill 7No.9 Jalan Stesen Sentral 5Kuala Lumpur Sentral,

50470 Kuala Lumpur

Or email your application to hc@pidm.gov.my

Section APERSONAL DETAIL

Name as per NRIC:

Residential Address:

:

House Tel. No.:Mobile No.:

NRIC No. :Email Address:

Nationality:Gender:

Date of Birth:

Section BUniversitIES and Field of StudIES

NoCourseSUniversitIES

1.1.

2.2.

3.3.

Section CEDUCational Qualification/Extra Curricular Activities

SPM or O Level or equivalent:

Name of School:

Year Completed:Final Grade:

Detailed Grade:

NOSUBJECTGRADENOSUBJECTGRADE

1.11.

2.12.

3.13.

4.14.

5.15.

6.16.

7.17.

8.18.

9.19.

10.20.

STPM or Matriculation or A Level or equivalent:

Name of School:

Year Completed:Final Grade:

Detailed Grade:

NOSUBJECTGRADENOSUBJECTGRADE

1.6.

2.7.

3.8.

4.9.

5.10.

Other Qualifications or Awards ReceivedNONAME OF QUALIFICATION OR AWARD RECEIVEDAWARDED BYDATE OF AWARD

1.

2.

3.

4.

5.

Extra Curricular ActivitiesNOname of SocietIES / ClubS / Sports / Other ActivitiesPosition heldYEAR

Section DFamily & INCOME DETAILS

Legal Guardian, where applicable:

Fathers Name:Mothers Name:

Age:Age:

NRIC No.:NRIC No.:

Occupation:Occupation:

Name of Employer:Name of Employer:

Address of Employer:Address of Employer:

Date Start:Date Start:

Office Tel. No.:Office Tel. No.:

Mobile No.:Mobile No.:

SUMMARY OF INCOME [Please attach relevant documents, i.e. salary slip, statement of income, where applicable]

Immediate Family MembersNett Income (RM)

1.Legal Guardian, where applicable

2.Father

3.Mother

4.Applicant

Other sources of income (please specify)

5.

6.

7.

TOTAL

NAMES AND PARTICULARS OF SIBLINGS [Please use separate sheet if necessary]

NoNameAgePlease state occupation or if still studyingName of School/College/University/ EmployerPlease state if the person is in receipt of a Scholarship from any OrganisationNett Incomeper month (RM)

1.

2.

3.

4.

5.

Do you have relative(s) working at PIDM? If Yes, please furnish details: Yes ( ) No ( )

Section eFinancial assistance

Are you presently receiving any financial assistance from any institution / foundation / government, etc? If Yes, please furnish details: Yes ( ) No ( )

Have you applied for any other Scholarships/Grants/Educational Loan? If Yes, please furnish details:

Yes ( ) No ( )

Section Fessay

Please submit a written essay in English of approximately 1000 words on your chosen field and your aspirations in contributing to the financial services landscape and the country in general. [Please use separate sheets of papers if the column provided is not sufficient]

Section GReferees

Please provide names, addresses, occupations and contact nos. of two (2) referees who are not related to you for us to contact as character references.Referee 1:Name as per NRIC:

Residential Address:

:

House Tel. No.:Mobile No.:

NRIC No. :Email Address:

Referee 2:

Name as per NRIC:

Residential Address:

:

House Tel No.:Mobile No.:

NRIC No. :Email Address:

I, _______________________________________________, I/C No. _________________________________ do hereby certify that all information provided in this application are true and accurate to the best of my knowledge and have not withheld any material information which might influence the consideration of this application. I understand that any misrepresentation/false declaration or omission will result in cancellation or withdrawal of any scholarship awarded. I also authorise any investigation of the above information for the purposes of verification.

__________________________________________

___________________________________

Applicants Signature

DateFOR OFFICE USE ONLY

Date Application Received & Received by:

Shortlisted for interview

Yes

No

Comments:-

CHECKLISTPlease ensure all the documents listed below are included in your scholarship application submission:-

Completed application form

Certified true copy of National Registration Identification Card (Both Sides on A4 paper)

Certified true copy of Sijil Pelajaran Malaysia transcript

Certified true copy of applicants/parents/guardians most recent EA/BE Form/Payslips

Tax Return Form /any other proof of income

1000 word essay

Recent passport-sized colour photograph

Acceptance/Offer Letter by University or private college to undertake a field of study as approved by PIDM

PIDM accepts documents that are certified by any of the following individual:-

1. Grade A Government Officer

2. School Principal/Headmaster

3. Commissioner of Oath

4. Ketua Kampung

5. Ahli Jawatankuasa Kemajuan dan Keselamatan Kampung

6. The employer or authorised representative of the employer

Please paste you recent passport- sized photograph here

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