YAYASAN SULTAN ISKANDAR JOHOR

(125568-W)

Scholarship at University Teknologi Malaysia

SCHOLARSHIP APPLICATION FORM

 All questions and essay in this application must be completed AFFIX
 Where inapplicable, put NIL / NA RECENT
PHOTOGRAPH

Course of Degree Applied For /

Currently Pursuing

A. PERSONAL DETAILS

Full Name:………………………………………………… Other Name (if any)………………………………….

(as in NRIC/Passport)

New NRIC No: …………………………………………… Old NRIC No: ……………………………………….

Date of Birth: ……………………………………………… Place of Birth: ……………………………………….
Nationality: …………………………. Age: …………….......................... Sex: ………………………..
Race: ………………………………... Religion: ………………………… Marital Status: ………………

Permanent Address: Mailing Address:

House Telephone No: Handphone No:

Other Contact No: E-mail Address:

B. EDUCATION (in chronological order)

School/College/University Period Course of Study Certificate/Diploma

Attended From (mth&yr) To (mth&yr) Obtained

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C. LANGUAGES & DIALECTS

Written : …………………………………………………………………………………………………
Spoken : …………………………………………………………………………………………………

D ACADEMIC QUALIFICATIONS

STPM/MATRICULATION/DIPLOMA DETAILED RESULTS (underline relevant exam)

Year: ……………………..

Subject Grade/GPA

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Aggregate (if applicable): ………….

Have you been offered admission to UTM?

(If yes, please state):

Name of Faculty Course of study Period Period of

Commencement Expected to Course
Date (mth&yr) Complete (mth&yr) (Years)

E. SCHOLARSHIP & LOAN

Have you been offered any scholarship award/bursary/study loan?

(If yes, please specify):

Name of Sponsor (s) Scholarship/Loan Value (RM) Amount Received to Date

(RM)

F. FAMILY BACKGROUND

(a) Name of Guardian (father/mother, etc.):……………………………………………… Age:………………………..

Where Employed:……………………………………………………………………... Tel. No:…………………….
Company’s Address: …………………………………………………………………………………………………...
…………………………………………………………………………………………………...
Occupation: …………………………………………..……….Salary/Income per Month: RM…………………….

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(b) Mother, Brothers & Sisters

Name Relationship Age Occupation (if schooling, state Salary/Income

name of School/University) per Month (RM)

(c) Total family income per month: RM………………….

How much financial assistance can your family offer you per month? RM………………….
(d) Property (e.g. land, house, etc)

Type Estimated Value (RM) Type Estimated Value (RM)

(e) Other Income (e.g. rent, funds, etc): …………………………………………………………………………………..

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G. EXTRA-MURAL ACTIVITIES (Name the activities you are good at):

(i) At school: …………………………………………………………………………………………………...

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(ii) At university: …………………………………………………………………………………………………...

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H. OTHER MATTERS

Hobbies: …………………………………………………………………………………………………...
Ambition: …………………………………………………………………………………………………...

Have you ever been convicted of any criminal offence? Yes / No*
If yes, please state: …………………………………………………………………………………………………...
Do you suffer from any physical handicap / illness? Yes / No*
If yes, please state: …………………………………………………………………………………………………...

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I declare that the information given above is correct and true. I understand that any false information or documents
given may render me liable to disqualification. Even if accepted, willful suppression of any material will similarly be
penalized.

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Signature of Applicant Date

IMPORTANT NOTES:
1. Applicants are reminded NOT to send certificates and testimonials (original or copies) when submitting
application form.
2. Incomplete application will not be considered.
3. Write ‘Scholarship Award’ and indicate the course applied for on the top left hand corner of the envelope.

I. ESSAY CONTRIBUTION (To attach extra sheet if necessary)

Please write (in English) in approximately 300 words ‘WHY DO I NEED A UNIVERSITY EDUCATION’.

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