The CP-IIUM SCHOLARSHIP PROGRAMME 2010/2011

(3 sets of Applications need to be sent to the Colombo Plan Secretariat on or before 30 December 2009
At the same time apply online at www.iiu.edu.my )

Recent Photograph

FORWARDED BY THE GOVERNMENT OF _________________________________________

Area of Specialization: Institution: International Islamic University Malaysia Kuala Lumpur Malaysia 1. PERSONAL INFORMATION Full Name as given in the passport (Underline the surname / last name): Date of Birth / / Nationality: Passport Number: Date of Expiry: Home Address: Place of Birth No. of Children Sex Male/ Female* Religion: Marital Status Single/ Married

Tel. Number:

2. PRESENT EMPLOYMENT Designation Office Address Telephone Number Fax Number E-mail Address Name of Employer Employers Address Fax/ E-mail Telephone Number Date of appointment to the present position / /

3. EMPLOYMENT RECORD (please show most recent posts first) Titles of Posts held Present Post Dates of Service Name and Address of Employer Type of Organisation Job title and brief description of your duties indicating any personal responsibility

Previous Post

Previous Post

4. EDUCATION RECORD

Educational Institution

Location

Years Attended From To

Degrees, Diplomas and Certificates received

Subjects or Special fields of study

5. PUBLICATIONS / RESEARCH EXPERIENCE Please list your publications or research experience if any.

6. ADMISSION ESSAY

On a separate sheet of paper, write an essay that outlines your personal and career goals, your desire to do graduate studies and commitment to attend the yearlong intensive MA programme. It should also indicate your reasons for applying for this course. This essay should be typewritten and not more than one page long. 7. ENGLISH LANGUAGE PROFICIENCY

Test TOEFL IELTS Other (Please specify)

Date Taken

Score / Grade

(Please attach a copy of the certificate). (b) Mother tongue: _____________________________ 8. REFEREES First Referee Name: _______________________ Post: _______________________ Second Referee Name: ______________________ Post: ______________________

Address: ______________________ Address: _____________________ _______________________ _______________________ ______________________ ______________________

9. Name and Address of a Relative or Friend in

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Name and Address of person to be notified in

Malaysia (if any) Name:______________________________ Address:_______________________________ __________________________________ ____________________________________ Telephone:___________________________

an emergency Name:_______________________________ Address:______________________________ ___________________________________ ____________________________________ Telephone:___________________________

I hereby apply for admission to the USM/Colombo Plan Master of Social Science programme. If admitted I agree to abide by its rules and regulations. I certify that to the best of my knowledge the statements made by me above are true and correct. _________________________ Date _____________________ Signature

_________________________________________________________________ Recommendations from Nominating Agency ____________________________________ (Signature of certifying government officer)

Seal of Nominating Agency

Name: ________________________________ Designation: ___________________________ Agency: _______________________________

The CP - IIUM SCHOLARSHIP PROGRAMME 2010/2011 APPLICANT RECOMMENDATION

Applicant Name:________________________________

Date: ___________

The above applicant has applied for admission to the above programme, and has given your name as a reference. We would appreciate your evaluation of the applicants personal and academic qualities. In particular, we were interested in knowing, whether in your judgement, the applicant is sufficiently prepared to pursue graduate work in the field of international studies. The following check list is intended to facilitate your assessment. You may, if you prefer, attach a separate letter. Personal Traits Intellectual ability Analytical ability Motivation and diligence Originality and initiative Judgement Ability in written expression Ability in oral expression Emotional stability Integrity Considering this applicant with his/her peers, how would you rate this applicant. T Top 10% o p 5 % Top 25% Top half Lower half Excellent Very good Good Average Below Average

Please amplify your estimate of the applicant regarding his/her general intellectual ability.

Signature: ___________________________ Name: ____________________________

Position:___ _________________________ Thank you for your assistance. Please seal this recommendation in an envelope, sign across the flap and return it to the applicant. The applicant has been instructed to submit this recommendation together with the rest of his/her application.

MEDICAL REPORT ON STUDENT APPLYING FOR ADMISSION TO FULL TIME COURSE IN MALAYSIA

1. 2.

Name of Applicant Age ...............

3. Family History ................................... ...................................... 4. Personal History: Details of important illness, accident or operation should be given together with subsequent treatment particular should be made concerning any form of tuberculosis, rheumatic fever, cholera, fever, dyspepsia, epilepsy, diabetes, nervous or mental illness and known allergies. 5. Present Condition: a. Height b. Weight c. Physique Respiratory System: a. Nose b. Chest Expansion c. Complete X ray Report of the chest Film No: Hospital: Circulatory System: a. Pulse b. Blood Pressure c. Heart d. e. f. Vaccination Tuberculin test result Blood group d. e. Pharynx Lungs (R & L) Date:

6.

7.

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Alimentary System: a. Appetite b. Bowels c. Tongue d. Liver e. Haemorrhoids Nervous System: a. Temperament b. Hearing Reproductive System: a. Varicose b. Gonorrhoea Urinary System: a. Specific Gravity b. Sugar c. Albumin Is the a. b. c.

f. g. h. i.

Digestion Teeth Spleen Rupture

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c. d. c.

Reflexes Sight Syphilis

10.

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d. e.

Deposits Miscellaneous

12.

candidate at present: Undergoing a treatment Receiving medical attention Requiring medical attention: If so please give details

I certify that the above candidate is medically fit to undertake a course in Malaysia. Signature of Physician:.......... Date: Name: . Address: ... . 13. Certification from Nominating Agency: I certify that the candidate has been medically examined by a qualified and registered medical practitioner. Signature: Name: Rank/ Title: Agency: .. .. .. ........

Seal of the Nominating Agency:

Note: In completing this form, particular attention should be paid to the following points: a. X-ray of chest to rule out any tuberculosis or chronic pulmonary disease, where the film is entirely normal b. Kidneys no evidence of renal lesion should be present. c. Eyesight Severe errors of refraction should not be passed as these should only give trouble during the years of training. d. Hearing deafness should be considered of definite bar.

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