Application Form CS PDF

For OFFICIAL USE ONLY
App No.
FORM CS-01
UBD CHANCELLORS SCHOLAR

APPLICATION FORM
Universiti Brunei Darussalam
Please return your completed application form to the following address before the closing date for application: UBD Chancellors Scholar Secretariat
Administration Building
Universiti Brunei Darussalam
Jalan Tungku Link
Gadong BE1410
Brunei Darussalam
www.ubd.edu.bn
Tel: +673-2463001 Ext 1160/1900/1653
Fax: +673-2460757
Email: chancellor.scholarship@ubd.edu.bn
Website: http://www.ubd.edu.bn
You are required to submit one set of the completed application. Each application includes: 1. Completed application form (CS-01)
2. Two recent passport-sized photographs
3. Supporting documents as per checklist at the end of this application form
NOTE: Certified English translations must be submitted for supporting documents that are not in the English Language. Online application is currently
not available.
PERSONAL PARTICULARS (Please print in BLOCK letters)

Name Mr / Miss _________________________________________________________________
(As in Identity Card)
____________________________________________________________________________________
IC No. _______ -__________________
Colour ________________________
Nationality ______________________
Ethnic Group ___________________
Date of Birth ____________________
Birthplace _____________________
Please attach 2x recent

passport size photograph
Age________
(dd/mm/yy)
Religion ________________________
Domicile ________________________________________
(Country you live in permanently)
Passport No. _____________ Place of Issue _____________ Date of Isssue __________ Date of Expiry _______________
(dd/mm/yy)
(dd/mm/yy)
Permanent Home Address _______________________________________________________________________________________

____________________________________________________________________________________________________________
Contact No (s)
____________________ Home
____________________Mobile
____________________ Fax*
Mailing Address ______________________________________________________________________________________________

(if different from above)
___________________________________________________________________________________________________________
Other Contact No(s) ______________________________
Email* __________________________________________
*Applicants are strongly advised to provide either a fax no. or an e-mail address to facilitate correspondence)
UBD Chancellors Scholarship
FAMILY INFORMATION
Name of Parent / Guardian ______________________________________________________________________________________
Male Female
IC No. _______ -__________________ Colour ________________________ Ethnic Group _______________________
Occupation __________________________________
Appointment __________________________________________
Employer __________________________________________________________________________________________
Mailing Address _____________________________________________________________________________________
__________________________________________________________________________________________________
Contact No(s) ________________ Home
_________________ Mobile
____________________ Office
Fax ____________________________
Email ____________________________________________
Name of Parent / Guardian ______________________________________________________________________________________

Male Female
IC No. _______ -__________________ Colour ________________________ Ethnic Group _______________________
Occupation __________________________________
Appointment __________________________________________
Employer __________________________________________________________________________________________
Mailing Address _____________________________________________________________________________________
__________________________________________________________________________________________________
_________________ Mobile
____________________ Office
Fax ____________________________
Email ____________________________________________
Have any of your family members received the UBD Chancellors Scholarship or from Ministry of Education Goverment Scholarship in
the past?
Yes
No
If yes, please list their names, relationship to you and year of award.
1.
______________________________________________________________________________________________________
2.
______________________________________________________________________________________________________
3.
______________________________________________________________________________________________________
Do you have family members currently employed by Universiti Brunei Darussalam?
Yes
No
If yes, please list their names, rank, current posts and their relationship to you.
1.
______________________________________________________________________________________________________
2.
______________________________________________________________________________________________________
3.
______________________________________________________________________________________________________
EDUCATIONAL BACKGROUND
Please indicate Examining Board where appropriate, e.g. Cambridge Examination Board / London Examination Board / International
Baccalaureate and/or Equivalent. Please submit official true copies results / transcripts.
First / Masters Degree
University ___________________________________________________________________________________________________
Address ______________________________________________________________________________________________________
_____________________________________________________________ Contact No. _____________________________________
Fax _____________________________
Email ____________________________________________________________________
Reason for leaving _____________________________________________________________________________________________

Date of Attendance (From) ___________________________________________ (To) _______________________________________
(mm/yyyy)
Date
Subject
(mm/yyyy)
(Taken / will be taking)
(mm/yyyy)
Semester
Numerical and/or
Level Grade
GCE A / AS Level / STPUB / IB or Equivalent

School / College / Institutions _____________________________________________________________________________________
Address ______________________________________________________________________________________________________
_____________________________________________________________ Contact No. _____________________________________
Fax _____________________________
Email ____________________________________________________________________
Reason for leaving _____________________________________________________________________________________________

Date of Attendance (From) ___________________________________________ (To) _______________________________________
(mm/yyyy)
Date
Subject
(mm/yyyy)
(Taken / will be taking)
(mm/yyyy)
Examining Board
Level
(A/AS)
Numerical and/or
Level Grade
PROFESSIONAL QUALIFICATION / CERTIFICATION

List your current and most recent qualification / certification and first and submit documentary evidence.
From
To
(dd/mm/yyyy)
(dd/mm/yyyy)
E.g. 01/01/2000
07/01/2000
Organisation / Institution / Location
Certificate (C) / Diploma (D)
Grade
Informatics (Singapore)
NETWORK + (C)
Pass
ACADEMIC, FINANCIAL AND SPORTING AWARDS

E.g. honours, distinctions, book prizes won. Please list in chronological order (since Form 4 or equivalent) and submit documentary
evidence.
Date
Award
Awarded by
(mm/yyyy)
EXTRA-CURRICULUAR AND CIVIC OR COMMUNITY ACTIVITIES

Please list in order of importance and submit documentary evidence.
Activity
Office /
Position Held
Elected /
Appointed /
Voluntary
Level (School /
District /
National)
Active Dates
(dd/mm/yy)
WORK EXPERIENCE
List your current and/or most recent position (if any).
Position ______________________________________________
Organisation _________________________________________
Date Employed (From) _______________________ (To) ______________________________ Part Time / Full Time
(dd/mm/yy)
(dd/mm/yy)
Responsibilities Held ____________________________________________________________________________________________

_____________________________________________________________________________________________________________
Nature of Organisation:
Government Non-Profit
Private Sector
Mailing Address ________________________________________________________________________________________________

Contact No. ______________________________
Fax No. ____________________________ E-mail _________________________
VOLUNTARY SERVICE
List your current and/or most recent position (if any).
Position ______________________________________________
Organisation _________________________________________
Date Volunteered (From) _______________________ (To) ____________________________

(dd/mm/yy)
Part Time / Full Time
(dd/mm/yy)
Responsibilities Held ____________________________________________________________________________________________

_____________________________________________________________________________________________________________
Nature of Organisation:
Government Non-Profit
Private Sector
Mailing Address ________________________________________________________________________________________________

Contact No. ______________________________
Fax No. ____________________________ E-mail _________________________
COURSES AND UNIVERSITIES

Please list the course and university you wish to apply to in the order of preference and remark appropraitely if you have submitted
your application to them (please submit proof of application if you have already done so). Note that you must gain admission to the
Universities specified in order to be considered for the scholarship.
Choice
Course of Study
University Location
Application
Submitted
Outcome of
Applciation
E.g.
Poticial Science
Harvard University (USA)
YN
Awaiting Reply
YN
YN
YN
YN
YN
YN
YN
YN
OTHER AWARDS / FINANCIAL ASSISTANCE SCHEMES

Have you applied for any other Scholarships / Bursaries / Loans from any other organisations? Yes
No
If yes, please furnish the following details:

Name of Award / Loan __________________________________________________________________________________________
Outcome of application: Successful
Unsuccessful Awaiting Offer
Duration of Award ___________________________________
Amount Granted _____________________________________
Approved Institution of Study ___________________________________________________________________________________

Any other Information _________________________________________________________________________________________
PREVIOUS APPLICATION
Have you previously applied for this Scholarship before?
Yes
No
STANDARDISED TEST INFORMATION

Please provide your TOEFL, SAT I and SAT II scores below. Note that you will need to sit for TOEFL and the SAT I in order to be
considered into most US Colleges / Universities some will also require the SAT II (please check with the university that you plan to
apply to). If you have booked a place in these said tests, please indicate the date(s) which you will be dong them. Please provide
highest scores.
I have not applied for the TOEFL
I have taken the TOEFL
I will be taking the TOEFL
Date (mm/yyyy) ___________________________
Date (mm/yyyy) _______________________________
Listening Score ___________________________

Writing Score
___________________________
Reading Score
___________________________
Total Score
___________________________
I have not applied for the SAT I

I have taken the SAT I
I will be taking the SAT I
Date (mm/yyyy) ___________________________
Date (mm/yyyy) _______________________________
Critical Reading Score
____________________
Math Score
___________________________
Writing Score
___________________________
Total Score
___________________________
I have not applied for the SAT II

I have taken the SAT II
I will be taking the SAT II
Date (mm/yyyy) ___________________________
Date (mm/yyyy) _______________________________
Subject and Score
________________________
Subject and Score
________________________
Subject and Score
________________________
Subject and Score
________________________
REFERENCES
Please provide the details of at least 2 referees below. Referee reports are to be completed by your Dean, Lecturer and/or
Club/Organisation Leader. The Referees report must be submitted in a sealed envelope with the referees signature across the flap of
the envelope.
Name ____________________________________________________
Position ___________________________________
Address of Organisation / Institution ________________________________________________________________________

_____________________________________________
Contact No. ___________________
Fax No. _______________
Email _______________________________________________________________________________________________
Name ____________________________________________________
Position ___________________________________

_____________________________________________
Contact No. ___________________
Fax No. _______________
Email _______________________________________________________________________________________________
Name ____________________________________________________
Position ___________________________________

_____________________________________________
Contact No. ___________________
Fax No. _______________
Email _______________________________________________________________________________________________
DECLARATION
Have you ever been convicted by a Court of law of any country?
Yes
No
If yes, please give details:

____________________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
I hereby declare that the information provided in this application is correct and the attachments are true to the best of my knowledge
and belief, and I have not witfully suppressed any material fact. I authorise Universiti Brunei Darussalam to obtain official records, if
necessary, from any educational institution I have attended.
As far as I am aware, I am medically fit and free from any medical problem which may impair my ability to attend to my studies.
I understand that any provision of inaccurate and false information or omission of information will render this applciation invalid and
that, if admitted on the basis of such information, I can be required to withdraw from the Scholarship.
Signature _____________________________________
Date ___________________________
FOR OFFICE USE ONLY
Date Received:
Application No:
10
ATTACHMENT 1 ESSAY
Please note that the essay is an important part of your Scholarship application. Please attach (not staple) a typed or computergenerated copy in thte space below. We strongly prefer that you do not handwrite your responses.
Write a short essay on who you are and what you are passionate about (400-500 words). The essay has to be an original piece, and no
part of it may be copied.
11
CONFIDENTIAL
ATTACHMENT 2 FACULTY DEAN REFERENCE FORM
TO THE APPLICANT
Please fill in the personal information below and forward this form to your current or previous Faculty Dean. Each reference must be
put in a sealed envelope, signed across the seal by the referee and returned to you by submission with your scholarship application
package.
PERSONAL INFORMATION
Name Mr / Miss _________________________________________________________________
_________________ Mobile
____________________ Office
Other Contact No (s) ______________________________________ Email ______________________________________________
University / Institution now /previously attended ____________________________________________________________________
TO THE FACULTY DEAN

The applicant has applied for the Universiti Brunei Darussalam Chancellors Scholarship. Please complete and return this form in a
sealed envelope to the applicant, who will forward it, unopened to the Scholarship Office, Universiti Brunei Darussalam. When you
seal the envelope, please sign across the seal.
Please write as fully as you can about the applicant from your perspective in providing us with but not limited to:
i.
ii.
iii.
Relevant factual data about the applicants academic performance and elevel fo extra-curricular achievement;
Your impressions of the candidates personal qualities and contribution to your school community; and
Information about personal circumstances that might have disadvantaged the applicant.
If you prefer to send a letter or statement (on the Universitys / Institutions letterhead and/or stamped), please feel free to do so.
Please check the rating boxes and include your letter or statement with this form and return both to Scholarship Office, Universiti
Brunei Darussalam. We appreciate the effort you expend on behalf of your student applying for this scholarship.
Name of person completing this report _____________________________________________________________________________
Position ___________________________________ University / Institution _______________________________________________
Contact No ___________________
Fax _____________________
Signature _________________________________
Email ________________________________________
Date _______________________________________________
University Code (if any) __________________________________

This report is based on (check all that apply):
Records
Personal contact with student Lecturers Observation
Others ____________________________________________________________________________________
How long have you known this applicant? ________________________________________________________________________

In what capacity? ___________________________________________________________________________________________
How often do you meet with this applicant? ______________________________________________________________________
How well do you know this applicant? ___________________________________________________________________________
12
TRANSCRIPT Please include an official copy of the applicants transcript of work completed from their Undergraduate (or the
equivalent). A brief explanation of titles or unusual grading systems would greatly assist us in assuring an accurate assessment of the
applicants level of achievement.
1.
ACADEMIC / INTELLECTUAL
In what way might you distinguish this applicants academic performance from that of other university-bound students?
Either through personal experience or in talking with lecturers, how would you characterise this applicants level of
intellectual curiosity and approach to learning?
2.
PERSONAL / INTERPERSONAL
a. What do you like best about this applicant? In what ways has this applicant made an impact either in your University/
Institution or in the community?
b.
3.
Are there any factors that might interefere with teh applicants academic performance and/or personal relationship
during his/her couorse of study
ADDITIONAL INFORMATION
a. Is there anything else we should know about this applicant (e.g. personal circumstances, character, values, a point of
interest or concern, particular interests, unusual accomplishments / special talents, obstacles overcame?)
Yes (Please explain fully on a separate sheet)
No
b.
What adjectives immediate come to mind in describing this applicant? ______________________________________
c.
Has the applicant ever violated an Honour Code or been placed on provation, suspended or expelled from your
institution?
13
4.
CHECKLIST
Rate the applciant in the checklist below. We are interested in your comparison of the applicant to other university-bound
students at the same level in your university / institution.
No Basis for
Judgement
Marginal
(Lower 50%)
Average
(Top 50%)
Good
(Top 25%)
Excellent
(Top 10%)
Superior
(Top 3%)
Intellectual ability
Analytic frame of mind
Problem-solving orientation
Quality of oral expression
Sense of humour
Initiative
Intellectual Curiosity
Creativity
Motivation and Energy
Self-Confidence
Leadership / Influence
Integrity
Concern for others
Respect for differences
Warmth of personality
Ability to meet deadline
Emotion maturity
Reaction to setbacks
Respect accorded by faculty
Respect accorded by peers
If you wish to give reasons for any of your ratings, please attach additional sheets as required.
5.
SUMMARY
Based on your experience as Faculty Dean (for _________ years), how would you summarise the applicants promise as
compared to that of other university / institution bound students in your university?
Marginal
(Lower 50%)
Average
(Top 50%)
Good
(Top 25%)
Excellent
(Top 10%)
Superior
(Top 3%)
Academic
Personal
Overall
Taking into account that the minimum eligibility requirement is 3 Grade A in GCE A Levels / 5 Mumtaz in STPUB, I
recommend this student for Univeriti Brunei Darussalam Chancellors Schoalrship.
Not at all
With Reservation
Fairly Strongly
Strongly
Enthusiastically
14
CONFIDENTIAL
ATTACHMENT 3 LECTURER / SUPERVISOR REFERENCE FORM
TO THE APPLICANT
Please fill in the personal information below and forward this form to your current or previous Lecturer / Supervisor who knows you
well and has taught or sueprvised you in an academic subject eitehr this year or the year before and is able to comment about y ou.
Each reference must be put in a sealed envelope, signed across the seal by the referee and returned to you by submission with your
scholarship application package.
Name Mr / Miss _________________________________________________________________
_________________ Mobile
____________________ Office
TO THE LECTURER / SUPERVISOR

i.
ii.
iii.
Description of the students intellectual and personal traits;

Abilities and achievemnts; and
Possible information about personal circumstances that might have disadvantaged the applicant.
If you prefer to send a letter or statement (on the Universitys / Institutions letterhead and/or stamped), please feel free to do so.
Position ___________________________________ University / Institution _______________________________________________
Contact No ___________________
Fax _____________________
Signature _________________________________
Records
Email ________________________________________
Date _______________________________________________
Personal contact with student Lecturers Observation
Others ____________________________________________________________________________________

In what capacity? ___________________________________________________________________________________________
In what subject(s) have you taught this applicant? _________________________________________________________________
15
1.
In what way might you distinguish this applicants academic performance from that of other qualified students? Please
comment on the students intellectual attitude, curiosity and enthusiasm for learning.
2.
Through which of the following does this applicant achieve academic success? (Check all that apply)
Hard work / diligence
Brilliance of mind
Love of learning
Other (Describe)
3.
What do you like best about this student? In what ways has this student made an impact in your class, the school and/or in
the community? Are there any factors that might interfere with the students academic performance and/or personal
relationship during his/her couorse of study?
4.
d. Is there anything else we should know about this applicant (e.g. personal circumstances, character, values, a point of
16
5.
CHECKLIST
No Basis for
Judgement
Marginal
(Lower 50%)
Average
(Top 50%)
Good
(Top 25%)
Excellent
(Top 10%)
Superior
(Top 3%)
Sense of humour
Initiative
Creativity
Self-Confidence
Integrity
Concern for others
Emotion maturity
6.
SUMMARY
Based on your experience as Lecturer / Supervisor (for _________ years), how would you summarise the applicants promise
as compared to that of other university / institution bound students in your university?
Marginal
(Lower 50%)
Average
(Top 50%)
Good
(Top 25%)
Excellent
(Top 10%)
Superior
(Top 3%)
Academic
Personal
Overall
Not at all
With Reservation
Fairly Strongly
Strongly
Enthusiastically
17
CONFIDENTIAL
ATTACHMENT 4 CLUB / ORGANISATION LEADER REFERENCE FORM
TO THE APPLICANT
Please fill in the personal information below and forward this form to a club / organisation leader who knows you well and is able to
comment about y ou. Each reference must be put in a sealed envelope, signed across the seal by the referee and returned to you by
submission with your scholarship application package.
Name Mr / Miss _________________________________________________________________
_________________ Mobile
____________________ Office
TO THE CLUB / ORGANISATION LEADER

i.
ii.
iii.
Description of the students/members intellectual and personal traits;

Abilities and achievemnts; and
Possible information about personal circumstances that might have disadvantaged the applicant.
If you prefer to send a letter or statement (on the organisation/universitys letterhead and/or stamped), please feel free to do so.
Position ___________________________________ Organisation _______________________________________________
Contact No ___________________
Fax _____________________
Signature _________________________________
Email ________________________________________
Date _______________________________________________
Personal contact with student Records
Others _________________________________________________________________________________________________
In what capacity? ___________________________________________________________________________________________
18
1.
In what way might you distinguish this applicants academic performance from that of other qualified students/members?
Please comment on the students intellectual attitude, curiosity and enthusiasm for learning.
2.
Through which of the following does this applicant achieve academic success? (Check all that apply)
Hard work / diligence
Brilliance of mind
Love of learning
Other (Describe)
3.
What do you like best about this student/member? In what ways has this student/member made an impact in your club,
organisation and/or in the community? Are there any factors that might interfere with the students/members performance
and/or personal relationship during his/her couorse of study?
4.
e. Is there anything else we should know about this applicant (e.g. personal circumstances, character, values, a point of
19
5.
CHECKLIST
No Basis for
Judgement
Marginal
(Lower 50%)
Average
(Top 50%)
Good
(Top 25%)
Excellent
(Top 10%)
Superior
(Top 3%)
Sense of humour
Initiative
Creativity
Self-Confidence
Integrity
Concern for others
Emotion maturity
6.
SUMMARY
Based on your experience as Lecturer / Supervisor (for _________ years), how would you summarise the applicants promise
as compared to that of other university / institution bound students in your university?
Marginal
(Lower 50%)
Average
(Top 50%)
Good
(Top 25%)
Excellent
(Top 10%)
Superior
(Top 3%)
Academic
Personal
Overall
Not at all
With Reservation
Fairly Strongly
Strongly
Enthusiastically
20
CHECKLIST
Please check that you have enclosed the following application in your scholarship application package.
Completed application form (incomplete applications will not be processed).
2 recent passport size photographs of yourself.
Copy of IC.
Copy of Passport
Certified true copies of Transcripts / Certificiates (e.g. GCE A Level Examination result slips)
TOEFL / IELTS, SAT I and SAT II Scores (If not yet sat for, please provide date of candidature).
Co-curricular Activities (CCA) reports / certificates
Attachment 1 Application Essay.
Attachment 2 Faculty Dean Reference Report.
Attachment 3 Lecturer / Supervisor Reference
Attachment 4 Club / Organisation Leader Reference Report.
Copies of any other supporting documents (certified true copies, where relevant)
REMINDER
It is your responsibility to ensure that all application material is sent in time
to the Scholarship Office, Universiti Brunei Darussalam by the application
deadline. Early application is encouraged.
21

Application Form CS PDF

Загружено:

Сведения о документе

Исходное описание:

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Application Form CS PDF

Загружено:

Авторское право:

Доступные форматы

For OFFICIAL USE ONLY

UBD CHANCELLORS SCHOLAR

Universiti Brunei Darussalam

PERSONAL PARTICULARS (Please print in BLOCK letters)

Ethnic Group ___________________

Date of Birth ____________________

Please attach 2x recent

Permanent Home Address _______________________________________________________________________________________

Mailing Address ______________________________________________________________________________________________

Name of Parent / Guardian ______________________________________________________________________________________

Do you have family members currently employed by Universiti Brunei Darussalam?

UBD Chancellors Scholarship

Reason for leaving _____________________________________________________________________________________________

(Taken / will be taking)

UBD Chancellors Scholarship

GCE A / AS Level / STPUB / IB or Equivalent

Reason for leaving _____________________________________________________________________________________________

(Taken / will be taking)

PROFESSIONAL QUALIFICATION / CERTIFICATION

UBD Chancellors Scholarship

Organisation / Institution / Location

Certificate (C) / Diploma (D)

ACADEMIC, FINANCIAL AND SPORTING AWARDS

EXTRA-CURRICULUAR AND CIVIC OR COMMUNITY ACTIVITIES

UBD Chancellors Scholarship

Responsibilities Held ____________________________________________________________________________________________

Mailing Address ________________________________________________________________________________________________

Fax No. ____________________________ E-mail _________________________

Date Volunteered (From) _______________________ (To) ____________________________

Part Time / Full Time

Responsibilities Held ____________________________________________________________________________________________

Mailing Address ________________________________________________________________________________________________

UBD Chancellors Scholarship

Fax No. ____________________________ E-mail _________________________

COURSES AND UNIVERSITIES

Harvard University (USA)

OTHER AWARDS / FINANCIAL ASSISTANCE SCHEMES

If yes, please furnish the following details:

Unsuccessful Awaiting Offer

Duration of Award ___________________________________

Amount Granted _____________________________________

Approved Institution of Study ___________________________________________________________________________________

UBD Chancellors Scholarship

STANDARDISED TEST INFORMATION

I will be taking the TOEFL

Date (mm/yyyy) ___________________________

Date (mm/yyyy) _______________________________

Listening Score ___________________________

I have not applied for the SAT I

I will be taking the SAT I

Date (mm/yyyy) ___________________________

Date (mm/yyyy) _______________________________

Critical Reading Score

I have not applied for the SAT II

I will be taking the SAT II

Date (mm/yyyy) ___________________________

Date (mm/yyyy) _______________________________

Subject and Score

Subject and Score

Subject and Score

Subject and Score

UBD Chancellors Scholarship

Fax No. ____ E-mail _

Date Volunteered (From) _ (To) ______

Fax No. ____ E-mail _

Other Contact No (s) Email ________

Other Contact No (s) Email ________

Other Contact No (s) Email ________