KUOK FOUNDATION BERHAD

(9641-T)

Letter Box No. 110, 16th Floor UBN Tower, 10 Jalan P Ramlee, 50250 Kuala Lumpur
Tel: 03 - 2711 8428 E-mail: general@kuokfoundation.com Website: www.kuokfoundation.com

Borang permohonan untuk bantuan kewangan pelajaran

Application form for educational assistance
ARAHAN
INSTRUCTIONS
Taip atau tulis dengan jelas. Gunakan HURUF BESAR.
Please type or write clearly. Please use BLOCK LETTERS.
Gariskan nama keluarga anda.
Type or write your name in full as it appears in your NRIC and underline your surname.
Gambar TERBARU Pemohon

borang permohonan.

RECENT Photograph
of Applicant

(Sila rujuk Syarat Permohonan yang dilampirkan).

Tarikh tutup permohonan:

MAKLUMAT PEMOHON / PARTICULARS OF APPLICANT

Nama pemohon seperti kad pengenalan

Name of applicant as in NRIC

No. kad pengenalan

NRIC number
Lelaki
Male

Alamat rumah (Tetap)

Home address (Permanent)

Perempuan Taraf perkahwinan

Marital status
Female

Alamat surat-menyurat
Postal address

Poskod
Postal code

Bandar dan Negeri

City and State
No. telefon rumah
Home telephone no.

No. telefon bimbit

Handphone no.

Bandar dan Negeri

City and State
Alamat e-mail
E-mail address
Umur
Age

Tarikh dan tempat lahir

Date and place of birth
Kedudukan sekarang pada masa pemohonan
Present status at time of application

Menuntut sepenuh masa

Studying full-time

Poskod
Postal code

Kewarganegaraan
Citizenship
Bekerja tetap
Full-time employment

Bangsa
Race
Bekerja sementara
Part-time employment

FOR OFFICE USE ONLY

RECEIVED:
REMARKS:

REF. NO.:

BUTIR-BUTIR KURSUS / COURSE DETAILS

Kursus dipohon (pilihan pertama) / Sedang dituntut

Course applied (first choice) / Attending
Nama institusi
Name of institution

Lokasi institusi
Location of institution

Jangkamasa kursus
Duration of course

Mula kursus
Commencement of course (mm/yyyy)

Tamat kursus
Completion of course (mm/yyyy)

Butir - butir perbelanjaan diperlukan setahun (nyatakan dalam Ringgit Malaysia)

Breakdown of estimated expenses required per annum (in Malaysian Ringgit)
Yuran kursus
Tuition fees

Yuran lain
Other fees

Tempat tinggal
Accomodation

Makanan
Food

Perbelanjaan lain
Other expenditure

Jumlah
Total

Bilangan tahun bantuan diperlukan

No. of years assistance required

0
Sumbangan setahun daripada keluarga / sumber lain. Nyatakan sumber
Amount per annum which can be obtained from family / other sources. State sources

Jumlah bantuan dipohon setahun

Amount applied for per annum

MAKLUMAT KELUARGA / INFORMATION ON FAMILY

Nama bapa / penjaga

Father / Guardians name

Nama ibu
Mothers name

No. kad pengenalan

NRIC number

Umur
Age

No. kad pengenalan

NRIC number

Alamat
Address

Alamat
Address

Kerja sepenuh masa

Full-time employment

No. telefon rumah

Home telephone no.
Pekerjaan
Occupation

No. telefon bimbit

Handphone no.
Pendapatan kasar sebulan
Gross monthly income
Kerja separuh masa
Part-time employment

Perniagaan sendiri
Own business

Poskod
Postal code

Bandar dan Negeri

City and State

Poskod
Postal code

Bandar dan Negeri

City and State
No. telefon rumah
Home telephone no.
Pekerjaan
Occupation

Umur
Age

Bersara
Retired

Nama dan alamat majikan / perniagaan sendiri. Jika sudah bersara, nyatakan nama dan
alamat majikan / perniagaan sendiri yang terdahulu.
Name and address of employer / own business. If retired, state name and address of
previous employer / own business.

Kerja sepenuh masa

Full-time employment

No. telefon bimbit

Handphone no.
Pendapatan kasar sebulan
Gross monthly income
Kerja separuh masa
Part-time employment

Perniagaan sendiri
Own business

Bersara
Retired

Nama dan alamat majikan / perniagaan sendiri. Jika sudah bersara, nyatakan nama dan
alamat majikan / perniagaan sendiri yang terdahulu.
Name and address of employer / own business. If retired, state name and address of
previous employer / own business.

No. telefon pejabat

Office telephone no.

No. telefon pejabat

Office telephone no.

Butir - butir SEMUA adik-beradik (kecuali pemohon)

Particulars of ALL brothers and sisters (exclude applicant)
Nama
Name

Jantina Umur Taraf

Gender Age
perkahwinan
Marital status

Bil. anak
(jika ada)
No. of
children
(if any)

Pekerjaan (jika menuntut, nyatakan

peringkat pendidikan dan nama
sekolah / institusi)
Occupation (If studying, state level
of education and name of school /
institution)

No. telefon (rumah,

bimbit atau pejabat)
Telephone no.
(home, handphone
or office)

Pendapatan
kasar sebulan
Gross monthly
income

MAKLUMAT PENDIDIKAN / INFORMATION ON EDUCATION

Butir-butir sekolah pemohon pernah belajar

Details of schools previously attended by applicant
Nama sekolah
School name

Bandar dan Negeri

City and State

Tahun mula
Tahun tamat
Keputusan yang dicapai
Year commenced Year completed Qualifications obtained

KEPUTUSAN PEPERIKSAAN / EXAMINATION RESULTS

SPM /SPVM / O level atau kelayakan yang setaraf dengannya

SPM / SPVM / O level or equivalent

Tahun
Year

STPM / A level / Matrikulasi atau kelayakan yang setaraf dengannya Tahun

STPM / A level / Matriculation or equivalent
Year

Mata pelajaran
Subject

Gred
Grade

Mata pelajaran
Subject

Gred
Grade

Keputusan peperiksaan universiti / kolej / politeknik seperti gred keseluruhan / purata nilai gred kumulatif, jika ada
University / college / polytechnic examination results such as overall grades / cumulative grade point average, if applicable
Tahun pertama
First year

Tahun kedua
Second year

Tahun ketiga
Third year

Tahun keempat
Fourth year

PENCAPAIAN KO-KURIKULUM / CO-CURRICULAR ACHIEVEMENTS

Aktiviti-aktiviti semasa di sekolah / politeknik / kolej / universiti dan jawatan yang disandang
Activities in school / polytechnic / college / university and leadership positions held

Anugerah / hadiah yang dimenangi seperti pencapaian akademik, sukan dan pertandingan lain di sekolah / politeknik / kolej / universiti
Prizes / awards won such as academic / subject prizes, trophies, medals for sports / other competitions in school / polytechnic / college / university

BANTUAN KEWANGAN / FINANCIAL ASSISTANCE

Butir-butir bantuan termasuk pinjaman yang anda terima terdahulu dan sekarang, jika ada, oleh organisasi-organisasi atau sumber-sumber lain
Details of past and present assistance including loans, if any, received from other organisations or other sources
Tahun diterima Pinjaman atau biasiswa Nama organisasi / sumber lain
Name of organisation / other sources
Year received Loan or scholarship

Jumlah setahun
Amount per annum

Namakan organisasi lain yang anda pernah memohon biasiswa / pinjaman

Name other organisations you have applied to for scholarship / loan
Pernahkah anda memohon bantuan kewangan dari Yayasan Kuok Berhad sebelum ini?
Have you previously applied to the Kuok Foundation Berhad?

Ada
Yes

Tahun permohonan
Year of application

Jumlah bantuan diterima, jika ada

Amount of assistance received, if any

Nombor rujukan, jika ada

Reference number, if any

Tidak
No

Adakah adik-beradik anda menerima bantuan kewangan dari Yayasan Kuok Berhad?
Are any of your brothers / sisters assisted by Kuok Foundation Berhad?

Ada
Yes

Jika ada, nyatakan nama adik-beradik

If yes, state name of brother / sister

Tahun, jenis bantuan atau nombor rujukan kami

Year assisted, type of award or our reference number

Adakah adik-beradik anda memohon bantuan kewangan dari Yayasan Kuok Berhad pada tahun ini?
Have any of your brothers / sisters also applied to Kuok Foundation Berhad this year?

Ada
Yes

Jika ada, nyatakan nama adik-beradik

If yes, state name of brother / sister

Institusi sedang dituntut / dipohon

Institution attending / applied to

Tidak
No

Tidak
No

MAKLUMAT PERUJUK / INFORMATION OF REFEREES

Namakan dua perujuk yang mengenali pemohon dan keluarga pemohon sekurang-kurangnya 3 tahun. Perujuk boleh terdiri daripada saudara mara atau kawan rapat keluarga TETAPI
bukan daripada kalangan penuntut, ibubapa atau adik-beradik pemohon. Perujuk mestilah boleh dihubungi melalui telefon semasa waktu pejabat.
Name of two (2) referees who are known to the applicant and applicants family for a period of not less than 3 years. Referees can be relatives or close family friends BUT not
applicants own parents, brothers / sisters or fellow students. Referees should be contactable by telephone during office hours.
Nama (Encik / Cik / Puan)
Name (Mr / Miss / Mrs / Madam)

Nama (Encik / Cik / Puan)

Name (Mr / Miss / Mrs / Madam)

Alamat
Address

Alamat
Address

Bandar dan Negeri

City and State

Poskod
Postal code

Poskod
Postal code

Bandar dan Negeri

City and State

No. telefon rumah

Home telephone no.

No. telefon bimbit

Handphone no.

No. telefon rumah

Home telephone no.

No. telefon bimbit

Handphone no.

Pekerjaan
Occupation

No. telefon pejabat

Office telephone no.

Pekerjaan
Occupation

No. telefon pejabat

Office telephone no.

Jumlah tahun mengenali pemohon

No. of years known

Pertalian dengan pemohon

Relationship to applicant

Jumlah tahun mengenali pemohon

No. of years known

Pertalian dengan pemohon

Relationship to applicant

LAIN-LAIN MAKLUMAT / OTHER INFORMATION

Kenyataan lain untuk menyokong permohonan ini (contohnya kenapa ibubapa tidak mampu membiayai perbelanjaan pelajaran anda)
Other relevant information to support your application (e.g. why parents cannot afford your educational expenses)

1. Saya mengakui bahawa maklumat yang diberikan adalah benar dan saya tidak dengan sengaja menyembunyikan apa-apa maklumat yang dikehendaki
untuk permohonan ini.
I hereby declare that the information given in this form is true to the best of my knowledge and that I have not wilfully suppressed any material fact
relevant to this application.
2. Saya dengan ini memberi persetujuan untuk pengumpulan, perakaman, penyimpanan dan penggunaan data peribadi saya bagi tujuan memproses
permohonan ini dan juga untuk kegunaan pentadbiran seterusnya yang melibatkan apa-apa bantuan kewangan yang ditawarkan kepada saya, termasuk
tetapi tidak terhad kepada mana-mana kegunaan lain berkaitan dengan bantuan kewangan ini.
I hereby give consent for the collection, recording, retention, storage and use of my personal data for the purpose of processing this application and
subsequent administration of any study award offered to me, including but not limited to any other uses in connection with the study award.

Tarikh permohonan
Date of application

Tandatangan pemohon
Applicants signature

KUOK FOUNDATION EDUCATIONAL ASSISTANCE DATA FORM

FOR OFFICE USE

PLEASE FILL IN SECTIONS I, II, III, IV, V & VI ONLY

NAME OF APPLICANT

II

PARTICULARS OF COURSE

RACE

SEX
M

1. Name of Course
Applied

Attending

2. Name of *University / College / Polytechnic

BL

APPLICANTS REF. NO.

FINANCIAL STATUS
TY:
YPH:
REMARKS

CR KIV

FS:

No. of children
Ranking in family
No. studying

3. Course Year (in the coming academic session)

Father or : Age Guardian : Occ : GY -

III EXAMINATION RESULTS (Do not write on shaded boxes)

1. *SPM / SPVM / O Level results

Year
Mother

1A
2A

A+
A
A-

2. UEC results

3B
4B
5C
6C

B+
B
C+
C

7D
8E
9G

D
E
G

: Age : Occ : GY -

Siblings GY

Year

A1
A2

B3
B4

B5
B6

C7
C8

UEC refers to Unified Examination Certificate for Independent Chinese Secondary Schools in Malaysia.

3. *STPM / A Level results

A
B
C

A
AB+
B

4. Matriculation results

Year
D
E

BC+
C

Year

CD+
D

5. MUET results

*CGPA / Overall Grade

Band

6. Latest *University / College / Polytechnic results

Year

*CGPA / Overall Grade

IV HAVE YOU PREVIOUSLY APPLIED TO KF?

YES

NO

If yes, please state year applied :

ARE ANY OF YOUR * BROTHERS / SISTERS ASSISTED BY KF?

If yes, state his / her name :

VI HAVE ANY OF YOUR * BROTHERS / SISTERS ALSO APPLIED TO KF THIS YEAR?

If yes, please state his / her name :
Note: KF refers to Kuok Foundation Berhad and * delete whichever is not applicable

Please turn over to next page for instructions

DOCUMENTS CHECKLIST
(Please arrange your documents according to the order below)

PLEASE tick ( ) either Yes or No. If No please explain why under Remarks
Have you enclosed certified copies of

1.

University / College / Polytechnic acceptance letter

2.

Parents / Guardians proof of income for the past 2 years

3.

Brothers and sisters proof of income for the past 2 years, if they are working

4.

Letters or documents to prove that brothers and sisters are pursuing higher
education in universities / colleges / institutions

5.

University / College / Polytechnic results (Actual/Forecast)

6.

STPM / A Level / Matriculation / Foundation (Actual/Forecast) & MUET results

7.

SPM / SPVM / O Level / UEC results (Actual/Forecast)

8.

Identity card and birth certificate of applicant

9.

Birth certificates of all brothers and sisters

10. Parents / Guardians identity cards or death certificate, if deceased

11. School leaving certificates
12. School testimonials (if any)

Yes

No

Remarks

INSTRUCTIONS

PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY BEFORE FILLING

DATA FORM
1. Please write or type clearly in BLOCK LETTER and complete DATA FORM in ENGLISH.
2. Please state NA in those sections which are not applicable to you.
3. The DATA FORM should be attached to the front page of the Kuok Foundations official
application forms.
4. In SECTION II, Nos. 1 & 2 you should state only your first choice of course and
university / college / polytechnic, if you are waiting for acceptance into university /
college / polytechnic.
5. In SECTION II, No. 3, Course Year refers to whether you are in Year 1, 2 etc. in
the new academic session.
6. In SECTION III, Nos. 1, 2 & 3, please state number of distinctions or credits or passes
obtained, for example :
SPM RESULTS 2009
Bahasa Melayu
Bahasa Inggeris
Pendidikan Moral
Sejarah
Mathematics
Additional Mathematics Physics
Chemistry
Biology
Bahasa Cina
English for Science
and Technology

TO COMPLETE IN THIS MANNER

A+
AB
AB
C+
B+
B+
B+
C+
A

1. *SPM / SPVM / O Level results

1A
2A

A+
A
A-

1
1
2

3B
4B
5C
6C

B+
B
C+
C

3
2
2

Year

7D
8E
9G

2009
D
E
G

7. Please ensure that all sections of the application form have been completed. Incomplete
application will be disqualified.

DEADLINE FOR SUBMISSION OF DOCUMENTS

If any of the documents are not immediately available, please submit them within 1 month
from the closing date for application.