KUMPULAN WANG BIASISWA TAN SRI MANICKAVASAGAM

(Founded in 1972 Registration No: 1101, Selangor)

Tingkat 3, Menara Manickavasagam, No. 1 Jalan Rahmat, 50350 Kuala Lumpur.
Tel: 03-40400700 Fax: 03-40415681
Email: kwbtsm@gmail.com

APPLICATION FOR STUDY LOAN

Applicants
Passport Size
Photograph

APPLICANT'S PARTICULARS
Full Name as Appearing On Identity Card: _______
Identity Card No: __________ ________

___

Permanent Address: __________________

___________
Citizenship

______

_________________________________________________________
______________________________________________________________

_________________________________________________________________

_____________________

__________________________________________________

: ___________

________________

Marital Status: ___________

_______

Date of Birth : ___________

___ _________________

Place of Birth: ___________

____________ ________

Contact Number: __________ ________

__

Email Address:

___________

UNIVERSITY / COLLEGE DETAILS

University / College: _________

______________________________________________________________________________

Address: __________________________________________________________________________________________________
___

_______________________________________________________________________________________________

Faculty / Course: ____________________________________________________________________________________________

Year of Study (Current) : ___________

___ ______________

Duration of Course: _____

How do you get to know about KWBTSM? _

Earlier Loan If Any, From

________ __

KWBTSM to you? Yes / No: ________ If Yes, state Amount: ___

_____
___ ______________

____________

______________

Other Scholarship / Bursaries / Loans - Applied for / Approved: ________ ____

____________

FEES STRUCTURE
Total fees for Course: RM _____

Other Expenses (Including food, transportation & etc): RM __

Total amount needed: RM _

CONTRIBUTION FROM OTHERS TO APPLICANTS (RM)

PARENTS / GUARDIAN /
FAMILY

RELATIVES / FRIENDS

RM

RM

__

PTPTN
RM

SCHOLARSHIP
RM

OTHER LOANS
RM

KWBTSM/ADMIN/LOAN/2012/Email Annand(Page 1/4)

APPLICANTS PARENTS / GUARDIANS PARTICULARS

DETAILS

FATHER

MOTHER

GUARDIAN

Name (as per I/C)

Permanent Address

Occupation

Place of Employment
& Address

Income (per month)

Telephone No

Income of Applicant's Parents / Guardian from Other Sources: _________

____ Amount Per Month: _________

_ _______

APPLICANTS HUSBAND / WIFE PARTICULARS

DETAILS

HUSBAND / WIFE

Name (as per I/C)

Permanent Address
Occupation
Place of Employment
Income (per month)
Telephone No

PROPERTY OWNED BY APPLICANTS PARENTS / GUARDIAN (MOVABLE AND IMMOVABLE)

NO

No
DETAILS OF PROPERTY

ADDRESS

VALUE

INCOME DERIVED PER MONTH

APPLICANTS PARENTS DEPENDENTS OTHER THAN APPLICANT

NO

No

NAME

AGE RELATION TO PARENTS / GUARDIAN

SCHOOLING / COLLEGE

KWBTSM/ADMIN/LOAN/2012/Email Annand(Page 2/4)

SELF SUPPORTING BROTHERS / SISTERS OF APPLICANTS (INCLUDING BROTHERS / SISTERS IN LAW)

NO

NAME

OCCUPATION

INCOME PER
MONTH

State Briefly Any Other Reasons In Support Of This Application:

__________
____
_

____ _

MARITAL
STATUS

___

___

NO. OF CHILDREN
LIVING WITH PARENTS

AMOUNT CONTRIBUTION
OF APPLICANT

__________________________________
_____________________________________
_
_

Please name two Referees who are not related to you and to whom reference may be made for a report about your
circumstances:

DETAILS

REFEREE 1

REFEREE 2

Name (as per I/C)

Permanent Address

Occupation
Place of Employment
Income (per month)
Telephone No

The Surety must be a person unrelated to the Applicant and acceptable to the Board with a regular income of not less than
$1,500/- per month:

DETAILS

SURETY 1

SURETY 2

Name (as per I/C)

Relationship to Applicant
Identity Card No
Permanent Address

Occupation
Place of Employment
Income (per month)
Telephone No

_________________________

_________________________

Signature of Surety

Signature of Surety

Date:

Date:

KWBTSM/ADMIN/LOAN/2012/Email Annand(Page 3/4)

Declaration by Applicant:
I declare that all particulars given herein are true and complete.

_________________________

Applicant's Signature

Date:

Declaration by Parents / Guardian:

I declare that to the best of my knowledge, all the particulars given by the Applicant, who is my son/daughter,
are true and complete.

______________________

Date:

Parents / Guardian Signature

Kindly take note that you are required to send your application form together with your supporting documents for our
needful action.
DOCUMENT REQUIRED

Tick ( / )

Tick ( x )

Student I/C copy

Birth Certificate copy
Student 1 Passport Size Photo
Student ID Card ( Matric Card ) copy
SPM / STPM / SPV / Foundation / Diploma / Others Certificate copy
Offer Letter copy
Applicant Parents I/C copy and pay slip
Applicant Parents current three month pay slip
Statement of Account copy (Repayment Payee Account)
Sureties I/C copy (2 Person)
Sureties current three month pay slip (RM 1,500 above) (2 Person)

* All document to be certified from any group of professional.

FOR OFFICE USE ONLY:

Interview Date:
Interviewed By:
Amount Approved:
Amount of Repayment:
Checked By:
Remarks:

KWBTSM/ADMIN/LOAN/2012/Email Annand(Page 4/4)