PIDM 2015SCHOLARSHIP AWARD APPLICATION FORM
Please read the following instructions carefully before completing the application:- Each applicant is allowed to submit ONEapplication only.
- All required supporting documents MUST be certified ‘true copies’ as per the original documents by the relevant authorities.
- 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.
- 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.
- Please send the duly completed form with all the required supporting documents latest by
Human Capital Division
(Scholarship Programme)
Perbadanan Insurans Deposit Malaysia
Level 12, Axiata Tower (formerly known as Quill 7)
No.9 Jalan Stesen Sentral 5
Kuala Lumpur Sentral,
50470 Kuala Lumpur
Or email your application to
Section A / PERSONAL DETAILS
Name as per NRIC / :
Residential Address / :
:
House Tel. No. / : / Mobile No. / :
NRIC No. / : / Email Address / :
Nationality / : / Gender / :
Date of Birth / :
Section B / UniversitIES and Field of StudIES
No / CourseS / UniversitIES
1.
2.
3.
Section C / EDUCational Qualification/Extra Curricular Activities
SPM or ‘O’ Level or equivalent:
Name of School / :Year Completed / : / Final Grade / :
Detailed Grade:
NO / SUBJECT / GRADE / NO / SUBJECT / GRADE1. / 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:
NO / SUBJECT / GRADE / NO / SUBJECT / GRADE1. / 6.
2. / 7.
3. / 8.
4. / 9.
5. / 10.
Other Qualifications or Awards Received
NO / NAME OF QUALIFICATION OR AWARD RECEIVED / AWARDED BY / DATE OF AWARD1.
2.
3.
4.
5.
Extra Curricular Activities
NO / name of SocietIES /ClubS /Sports/Other Activities / Position held / YEARSection D / Family & INCOME DETAILS
Legal Guardian, where applicable / :
Father’s Name / : / Mother’s 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 Members / Gross Income Per Month (RM)
1. / Legal Guardian, where applicable
2. Father
- Mother
5. / Applicant
Other sources of income eg. Rental, etc (please specify)
1.
2.
3.
TOTAL
Other Information: (Please tick at the appropriate column and provide the information accordingly)
1. Current residence: Owned, fully paid Owned, under mortgaged: Monthly instalment RM______
Rented: Monthly rentalRM______
2. Type of Residence (Please specify): ______(eg. bungalow/Semi-D/terrace house/condominium/ flat etc).
3. Do your parents/legal guardian own any lands / houses / shoplots or other immovable assets? Yes No
a) If yes, please state the type and estimated value : Type : ______Value : RM ______
4. Do your parents/legal guardian have any shares, unit trusts or other investments? Yes No
a)If yes, please state the type and estimated value : Type : ______Value : RM ______
- How many of your siblings (if any) contribute to the household income? ______
- Total monthly contribution from siblings is RM ______
NAMES AND PARTICULARS OF SIBLINGS
[Please use separate sheet if necessary]
No / Name / Age / Please state occupation or if still studying / Name of School/College/University/Employer / Please state if the person is in receipt of a Scholarship from any Organisation / Gross
Income
Per Month
(RM)
1.
2.
3.
4.
5.
6.
7.
8.
Do you have relative(s) working at PIDM? If Yes, please furnish details: Yes ( ) No ( )
Section e / Financial 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 F / EVALUATION
How did you find out about PIDM Scholarship programme? Please tick at the appropriate boxes.
Social Engine : Google Bing
Social Media : Facebook Twitter
Newspaper Advertisement: The Star Metro The Sun
Pen. Malaysia:
East Malaysia: Borneo Post New Sabah Times Utusan Sarawak
Others: Friends Family /Relatives Others: ______
(please state)
Section G / essay
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 H / Referees
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.Please ensure that you get the consent of the referees before disclosing their personal data to us.
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 / :
Notice: The personal data collected on this form will be used for purposes related to your scholarship application. These purposes include without limitation, to assess your eligibility leading to the selection for the scholarship programme, to conduct reference and background checks, and for verification of information. We will not disclose your personal data to any third party, whether located in or outside Malaysia, unless it is required for these purposes. Failure to provide the information requested for may influence the outcome of your application.By signing at the bottom of this form, you are consenting to the processing of your personal data for the purposes stated.
It is our policy to retain the personal data of unsuccessful applicants for a period of 12 months from the date of application. To access or correct your information, please write to the Human Capital Division to the attention of Recruitment Manager of telephone: 2173 7436 (details of which are on the first page of this form) with your name, correspondence address, contact number and details of your request.
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. I confirm that I have obtained the consent of my parent(s), legal guardian(s), siblings(s), referee(s) and/or other third parties to disclose their personal data as requested in this form.
______
Applicant’s SignatureDate
CHECKLIST
Please 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 and other higher education transcript
Certified true copy of applicant’s/parents’/guardian’s 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:-
- Grade A Government Officer
- School Principal/Headmaster
- Commissioner of Oath
- “Ketua Kampung”
- “Ahli Jawatankuasa Kemajuan dan Keselamatan Kampung”
- The employer or authorised representative of the employer
FOR OFFICE USE ONLY
Date Application Received & Received by / :Shortlisted for interviewYesNo
Comments:-PIDM SAF2015Page 1