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YAYASAN TAN SRI LEE SHIN CHENG Company No. 139943-U

Borang Permohonan Bantuan Kewangan untuk Pembelajaran di Institusi Pengajian Tinggi Application Form for Higher Education Assistance

ARAHAN 1. Taip atau tulis dengan jelas. Gunakan HURUF BESAR.

2. Taip atau tulis name penuh anda sepertimana yang terdapat didalam

kad pengenalan anda. Gariskan nama keluarga anda. 3. Pemohon yang telah memasuki universiti hendaklah menyatakan

tahun pengajian sama ada Tahun 1, Tahun 2 dan seterusnya atau Tahun terakhir bagi sessi akan datang.

4. Sekiranya ibu bapa telah bersara, tulis dalam kurungan jenis

pekerjaan, nama dan alamat majikan/perniagaan sendiri mereka sebelum bersara. Jika telah meninggal dunia, lampirkan salinan sijil kematian dan nyatakan juga pekerjaan, nama dan alamat majikan/perniagaan sendiri semasa hayatnya.

5. Sekiranya ruang menulis tidak mencukupi, gunakan kertas tambahan

dan lampirkan bersama borang permohonan. 6. Salinan-salinan yang telah disahkan bagi sijil beranak, sijil-sijil

peperiksaan dan lain-lain dokumen yang berkaitan seperti notis taksiran cukai pendapatan ibu bapa/penjaga hendaklah dilampirkan.

7. Borang permohonan yang telah lengkap hendaklah dikembalikan

sebelum 13hb Julai 2015 kepada: -

Sekretariat YAYASAN TAN SRI LEE SHIN CHENG Level 11, Two IOI Square, IOI Resort, 62502 Putrajaya, Malaysia

INSTRUCTIONS

1. Please type or write clearly. Please use BLOCK LETTERS. 2. Type or write your name in full as it appears in your NRIC and

underline your surname.

3. Those who are already in the University should state whether they are in Year 1, Year 2, etc or final year in the coming session.

4. If parent/parents are retired, state within brackets their occupation,

name and address of employer/own business before retirement, if deceased. Kindly submit death certificate and state former occupation, name and address of employer/own business.

5. If space is insufficient, please continue in a separate sheet and

attach the sheet to the application form.

6. Certified copies of birth certificate, examination certificates and other relevant documents such as income tax notice of assessment of parents/guardians must be attached.

7. Completed application form should be returned by

13th July 2015 to:-

Secretariat YAYASAN TAN SRI LEE SHIN CHENG Level 11, Two IOI Square, IOI Resort, 62502 Putrajaya, Malaysia

A MAKLUMAT PEMOHON / PARTICULARS FOR APPLICANT Nama pemohon (Encik /Cik / Puan) Name of applicant (Mr / Miss / Mrs /Madam)

No. Kad pengenalan NRIC number

Alamat rumah (Tetap) Home address (Permanent)

Alamat surat-menyurat Correspondence address

Bandar dan Negeri City and State

Poskod Postal code


Poskod Postal code

No. tel rumah Home tel no.

No. tel bimbit H/p No.

Alamat e-mail E-mail address

Tarikh dan tempat lahir Place and date of birth

Umur Age

Kewarganegaraan Citizenship

Kedudukan sekarang Present status

Jika menuntut, nyatakan peringkat pendidikan If studying, state level of education

Jika mahasiswa nyatakan tahun kursus bagi sessi akan datang If in University, state year of course in the coming session

Jika sedang bekerja, nyatakan pekerjaan If currently employed, state occupation

Jumlah tahun telah bekerja No. of years employment

Gaji terakhir diterima sebulan Last drawn salary per month

Gambar

TERBARU

Pemohon

RECENT

Photograph of

Applicant

B 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 dalan Ringgit Malaysia) Breakdown of estimated expenses required per annum (in Malaysian Ringgit)

Yuran kursus Tuition fees (RM)

Yuran lain Other fees (RM)

Tempat tinggal Accommodation

Makanan Food

Perbelanjaan lain Other expenditure

Jumlah Total (RM)

Bilangan tahun bantuan diperlukan No. of years assistance required

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 (RM)

C 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

Umur Age

Alamat Address

Alamat Address

No.tel rumah Home tel no.

No.tel bimbit H/p no.

No.tel rumah Home tel no.

No.tel bimbit H/p no.

Pekerjaan Occupation

Pendapatan kasar sebulan Gross income per month

Pekerjaan Occupation


Nama serta alamat majikan / perniagaan sendiri (jika sudah bersara, nyatakan jenis pekerjaan, nama dan alamat majikan / perniagaan yang terdahulu) Name and address of employer / own business (if retired, state type of employment, name and address of previous employer / own business)

Nama serta alamat majikan / perniagaan sendiri (jika sudah bersara, nyatakan jenis pekerjaan, nama dan alamat majikan / perniagaan yang terdahulu) Name and address of employer / own business (if retired, state type of employment, name and address of previous employer / own business)

No. tel pejabat Office tel no.


Butir-butir SEMUA adik beradik (kecuali pemohon) Particulars of ALL brothers and sisters (exclude applicant)

Nama Name

Jantina Sex

Umur Age

Taraf perkahwinan Marital status

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

Pekerjaan (jika menuntut, nyatakan peringkat pendidikan dan mana sekolah/institusi) Occupation (if studying, state level of education and name of school/institution)

No tel (rumah, H/p atau Pejabat) Tel no (home, H/p or office)


D MAKLUMAT PENDIDIKAN / INFORMATION ON EDUCATION Butir-butir sekolah pemohon pernah belajar Details of schools previously attended by applicant Nama sekolah School name

Bandar & Negeri City & State

Tahun mula Year commenced

Tahun tamat Year completed

Keputusan yang dicapai Qualifications obtained

E 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 STPM / A level / Matriculation or equivalent

Tahun Year

Mata pelajaran Subjects

Gred Grade

Mata pelajaran Subjects

Gred Grade

Keputusan peperiksaan universiti/ kolej seperti gred keseluruhan / purata nilai gred kumulatif, jika ada University / college examination results such as overall grades / cumulative grade point average (if applicable), attach result slip

Tahun 1 1st year

Tahun 2 2nd year

Tahun 3 3rd year

Tahun 4 4th year

F PENCAPAIAN KO-KURIKULUM / CO-CURRICULAR ACHIEVEMENTS Aktiviti-aktiviti semasa di sekolah / kolej / universiti dan jawatan yang disandang Activities in school / college / university and leadership positions held

Anugerah / hadiah-hadiah yang dimenangi seperti pencapaian akademik, sukan dan lain-lain pertandingan Prizes / awards won such as academic / subject prizes, trophies, medal for sports / other competitions

G BANTUAN KEWANGAN / FINANCIAL ASSISTANCE Butir-butir bantuan termasuk pinjaman yang diterima dahulu dan sekarang, jika ada, oleh organisasi-organisasi sumber-sumber lain. Details of past and present assistance, including loans, if any, received from other organizations or other sources

Tahun diterima Year received

Pinjaman atau biasiswa Loan or scholarship

Nama organisasi / sumber lain Name of organization / other sources

Jumlah setahun Amount per annum

Namakan organisasi-organisasi lain yang anda pernah memohon biasiswa / pinjamam Name other organizations you have applied to for scholarship/loan

Pernahkah anda memohon bantuan kewangan dari Yayasan TSLSC? Have you previously applied to the TSLSC Foundation? Jika pernah, nyatakan tarikh permohonan If yes, state date of application

Jumlah bantuan diterima, jika ada Amount of assistance received, if any

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

Jika ada, nyatakan nama adik-beradik If yes, state name of brother / sister

Tahun dan jenis bantuan Year Assisted and Type of Award

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

Jika ada, nyatakan nama adik-beradik If yes, state name of brother / sister

Institusi sedang dituntut / dipohon Institution attending / applied to

H MAKLUMAT PERUJUK INFORMATION ON 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. Names 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


Poskod Postal code


Poskod Postal code

No. tel rumah Home tel no

No. tel bimbit H/p no.

No. tel rumah Home tel no

No. tel bimbit H/p no.

Pekerjaaan Occupation


Pekerjaaan Occupation


Jumlah tahun mengenali pemohon No. of years known

Pertalian dengan pemohon Relationship to applicant

Jumlah tahun mengenali anda No. of years known

Pertalian dengan pemohon Relationship to applicant

I LAIN LAIN MAKLUMAT / OTHER INFORMATION Kenyataan lain untuk menyokong permohonan ini Other relevant information to support your application

Mengapa anda memilih kursus pelajaran ini? Why did you choose the course of study?

Saya mengakui bahawa maklumat-maklumat yang diberikan adalah benar dan saya tidak ada dengan sengajanya 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 willfully suppressed any material fact relevant to this application.

_______________________ ___________________ Tandatangan pemohon Tarikh permohonan Applicants signature Date of application

Nota: Pihak Yayasan berhak menolak dan membatalkan tawaran biasiswa sekiranya Pemohon didapati memberi sebarang maklumat palsu atau menyembunyikan sebarang maklumat.

Note: The Yayasan reserves its right to reject and to nullify its offer of scholarship/grant to any Applicant found to have provided any false information and/or withheld any material fact.

Tidak No

Ada Yes

Tidak No

Ada Yes

Tidak No

Ada Yes

YAYASAN TAN SRI LEE SHIN CHENG DATA CHECKLIST (To attach this to the front page of Application Form) Please check and fill in accordingly.

I NAME OF APPLICANT

SEX

*F / M

II PARTICULARS OF COURSE

1. Name of Course *Applied / Attending

2. Name of * University /College

3. Course Year (in the coming academic session)

III EXAMINATION RESULTS (Do not write in shaded boxes)

1. *SPM / SPVM / O Level results Year

1A A+ 3B B+ 7D D

A 4B B 8E E

2A A- 5C C+ 9G G

6C C

2. UEC results Year

A1 B3 B5 C7

A2 B4 B6 C8

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

3. *STPM / A Level results Year

A A

D B-

R

C-

A- C+ D+

B B+ E C D

C B

4. Matriculation results Year 5. MUET results

*CGPA / Overall Grade Band

6. Latest *University / College results Year

*CGPA / Overall Grade

*Delete whichever is not applicable

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 True Copies of Yes No Remarks

1 University/College acceptance letter

2 Document stating the course fee from the University

3 Academic Calendar

4 I/C or Birth Certificate of applicant

5 SPM / SPVM / 'O' Level / UEC results

6 STPM / 'A' Level / Matriculation / Foundation results

7 University/College results

8 School Leaving Certificates

9 School Testimonials (if any)

10 Parents' / Guardian's proof of income for the past 1 year

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

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Documents