Financial Year 2010/2011

YAYASAN PROTON

FOR HR USE ONLY DATE RECEIVED APPLICATION NO. STATUS SCORING

Latest Colour Passport Size Photo

A.
NAME NRIC NO. DATE OF BIRTH PLACE OF BIRTH RACE SEX RELIGION E-MAIL MOBILE NO. HOUSE TEL NO. PERMANENT ADDRESS

PERSONAL DETAILS
* Please attach Copy of NRIC

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CORRESPONDENCE ADDRESS

B.

SPM / SPVM DETAILS

(Please attach Copy of Results)

YEAR TAKEN NAME OF SCHOOL TOWN / STATE OF SCHOOL SUBJECTS i. ii. iii. iv. v. vi. vii. iix. ix. x. xi. xii. GRADES

C.

MATRICULATIONS / DIPLOMA
Letter & Results)

(Please attach Copy of Offer

UNIVERSITY MATRICULATIONS / DIPLOMA MAJORING (IF ANY) MONTH & YEAR OF COMMENCEMENT

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MONTH & YEAR OF COMPLETION CURRENT / FINAL CGPA

D.
1st CHOICE

APPLICATION TO DEGREE PROGRAM

UNIVERSITY DEGREE YEARS OF STUDY 2nd CHOICE UNIVERSITY DEGREE YEARS OF STUDY 3rd CHOICE UNIVERSITY DEGREE YEARS OF STUDY

E.

DEGREE PROGRAM
UNIVERSITY DEGREE MAJORING (IF ANY) CURRENT SEMESTER

(Please attach Offer Letter & Latest Results)

TOTAL NUMBER OF SEMESTERS MONTH & YEAR OF COMMENCEMENT MONTH & YEAR OF COMPLETION TUITION FEES PER YEAR

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CURRENT CGPA

F.
FATHER (Please attach NRIC)

FAMILY BACKGROUND

FULL NAME AS PER NRIC NRIC NO. MOBILE NO. STATUS / OCCUPATION COMPANY ADDRESS MONTHLY INCOME (Please attach
Payslip)

MOTHER (Please attach NRIC) FULL NAME AS PER NRIC NRIC NO. MOBILE NO. STATUS / OCCUPATION COMPANY ADDRESS MONTHLY INCOME (Please attach
Payslip)

SIBLINGS INFORMATION NAME i. ii. iii. iv. AGE OCCUPATIO N / FORM / STD COMPANY / SCHOOL / INSTITUTION MONTHL Y INCOME

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v.

G.

ADDITIONAL INFO FOR CHILDREN OF PROTON EMPLOYEES

STAFF NO. DATE JOINED

NAME OF EMPLOYEE

DESIGNATION / GRADE UNIT / DEPARTMENT DIVISION OFFICE CONTACT NO.

H.

CO-CURRICULAR ACTIVITIES Past 2 Years ONLY

LEVEL REPRESENTED (SCHOOL/DISTRICT/STATE/COUNTRY) TYPE OF SPORT

SPORTS ACTIVITIES (Please attach Certificates) YEAR

CLUBS / SOCIETIES (Please attach Certificates) YEAR LEVEL OF POSITION HELD (PRESIDENT/CHAIRMAN/SECRETARY ETC) NAME OF CLUB/SOCIETY

OTHER ACTIVITIES (Please attach Certificates) YEAR LEVEL OF POSITION HELD (MPP/HEAD OF RESIDENCE ETC) ACTIVITIES

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I.

OTHER INFORMATION

(Please attach Offer Letter of Loan/Sponsorship)

ARE YOU HOLDING PTPTN LOAN? IF YES, PLEASE STATE AMOUNT (RM) PER YEAR ARE YOU HOLDING OTHER SPONSORSHIP? IF YES, PLEASE STATE AMOUNT (RM) PER YEAR NAME OF ORGANIZATION / SPONSORSHIP

J. DECLARATION
I, hereby declare that the information given in this application form is complete, accurate and I agree to abide by the above conditions. I understand that any information given falsely or withheld will affect the decision of my application, and may result in my ineligibility for the scholarship award.

Signature of Applicant Date :

The complete application form with all relevant documents should be sent to below address:YAYASAN PROTON, GROUP HUMAN PROTON HOLDINGS BERHAD HICOM Industrial Estate Jalan Puchong-Shah Alam Seksyen 26 40000 Shah Alam SELANGOR DARUL EHSAN www.proton.com
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RESOURCE
CLOSING CLOSING DATE: DATE: 30 30 APRIL, APRIL, 2010 2010