2016 APPLICATION FORM FOR BCA-INDUSTRY Built Environment ITE sChOLARSHip

(Please type. Only Singapore Citizens or Singapore Permanent Residents may apply.)

Personal Particulars
Name: / Passport Size Photo
(Click below to insert photo)

NRIC:
Date of Birth:
Nationality: / Choose an item
Gender: / Choose an item
Race
Marital Status: / Choose an item
Contact Number: / Mobile: / Home:
Email Address:
Address (as in NRIC):
Mailing Address
(if different from above)
National Service (for males)
Status: / Choose an item / Date of Enlistment:
Rank: / Operational Ready Date (ORD):
Unit: / Company / Department:
Reasons for Exemption / Deferment from NS: (if applicable)
Current ITE Course
School Name: / Choose an item / Start Date / Choose an item / Choose an item
Course of study: / Choose an item / Expected Graduation Date: / Choose an item / Choose an item
Year of study: / Choose an item / Cumulative GPA:
Indicate if you are under Direct Entry Year 2 or DPP (Direct Entry Scheme to Polytechnic Programme) / Choose an item
Module Taken / Grade / Module Taken / Grade

Rev. date: 18 Nov ‘15

Highest Education Qualification (indicate past ITE certificate if applicable)
Highest Qualification: / Choose an item / Year Obtained Qualification:
School Name: / Course:
Examination Results (Please state below): / GPA (for Nitec graduates):
Subject / Module Taken / Grade / Subject / Module Taken / Grade
Family Particulars
Full Name / Relationship / Age / Occupation / Company/School
Other Information
(Please check the corresponding boxes.) / Yes / No
Have you been or are suffering from any disease / illness / major medical condition or physical impairment? If yes, please indicate:
Have you ever been convicted in a court of law in any country (including traffic offences)?
If yes, please indicate year and nature of offence:
Do you have any pending court case or police investigation?
Have you previously applied for this scholarship?
Have you applied or received any other scholarship / bursary / financial assistance schemes? If yes, please indicate:
Declaration
(Please check the box as your declaration.)
I declare that all the particulars in this application (and the attached documents, if any) are true to the best of my knowledge and belief, and I have not willfully suppressed any material fact. I acknowledge that I will be disqualified, or if accepted, my scholarship will be terminated without any notice if any particulars are found to be untrue or material facts have been willfully suppressed.

Please attach scanned copies of the following supporting documents with this application:

• Identity Card / Proof of Citizenship (Singapore Citizen or Singapore Permanent Resident)

• Higher Nitec / Nitec / GCE O-Level / N-Level examination results

• ITE Course admission letter / Student Pass

• CCA records and testimonials

Please email the completed form and scanned copies of documents to Ms Rachel Leu and Mr Tey Boon Hui (; ).

Page 1 of 1