PIDM 2012 SCHOLARSHIP AWARD APPLICATION FORM

Please read the following instructions carefully before completing the application:

1. Each applicant is allowed to submit ONE application only. 2. All required supporting documents MUST be certified true copies as per the
original documents by the relevant authorities. 3. All fields in the form must be filled up properly and clearly and must not be left blank. State Not Applicable or NA for areas that that are not applicable to you.

Please paste you recent passport- sized photograph here

4. Ensure your application is for courses at the public and/or private

universities and/or colleges approved by PIDM only, for which you have gained acceptance to.

5. Please send the duly completed form with all the required supporting
documents latest by 29 April 2012 to:General Manager, Human Capital (Scholarship Programme) Perbadanan Insurans Deposit Malaysia Level 12, Quill 7 No.9 Jalan Stesen Sentral 5 Kuala Lumpur Sentral, 50470 Kuala Lumpur Or email your application to hc@pidm.gov.my

SECTION A
Name as per NRIC Residential Address : : : House Tel. No. NRIC No. Nationality Religion Gender : : : : :

PERSONAL DETAIL

Mobile No. Email Address Race Date of Birth Marital Status

: : : : :

SECTION B
N O
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UNIVERSITIES AND FIELD OF STUDIES

COURSES UNIVERSITIES

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1. 2. 3.

SECTION C EDUCATIONAL QUALIFICATION/EXTRA CURRICULAR ACTIVITIES

SPM or O Level or equivalent: Name of School Year Completed Detailed Grade: N O 1. 2. 3. 4. 5. 6. 7. 8. 9. 10 . STPM or Matriculation or A Level or equivalent: Name of School Year Completed Detailed Grade: N O SUBJECT GRADE N O SUBJECT GRADE : : Final Grade : SUBJECT GRADE N O 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. SUBJECT GRADE : : Final Grade :

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1. 2. 3. 4. 5.

6. 7. 8. 9. 10.

Other Qualifications or Awards Received

N O
1. 2. 3. 4. 5.

NAME OF QUALIFICATION OR AWARD RECEIVED

AWARDED BY

DATE OF AWARD

Extra Curricular Activities N O NAME OF SOCIETIES / CLUBS / SPORTS / OTHER ACTIVITIES POSITION HELD YEAR

SECTION D
Legal Guardian, where applicable Fathers Name Age NRIC No. Occupation : : : : :

FAMILY & INCOME DETAILS

Mothers Name Age NRIC No. Occupation

: : : :

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Name of Employer Address of Employer

: :

Name of Employer Address of Employer

: :

Date Start Office Tel. No. Mobile No.

: : :

Date Start Office Tel. No. Mobile No.

: : :

SUMMARY OF INCOME
[Please attach relevant documents, i.e. salary slip, statement of income, where applicable] Immediate Family Members 1 . 2 . 3 . 4 . Legal Guardian, where applicable Father Mother Applicant Nett Income (RM)

Other sources of income (please specify) 5 . 6 . 7 . TOTAL

NAMES AND PARTICULARS OF SIBLINGS

[Please use separate sheet if necessary]
N o Name Ag e Please state occupation or if still studying Name of School/College/Universit y/ Employer Please state if the person is in receipt of a Scholarship from any Organisatio n Nett Income per month (RM)

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1. 2. 3. 4. 5. Do you have relative(s) working at PIDM? If Yes, please furnish details: Yes ( ) No ( )

SECTION E

FINANCIAL ASSISTANCE

Are you presently receiving any financial assistance from any institution / foundation / government, etc? If Yes, please furnish details: Yes ( ) No ( )

Have you applied for any other Scholarships/Grants/Educational Loan? If Yes, please furnish details: Yes ( ) No ( )

SECTION F

ESSAY

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Please submit a written essay in English of approximately 1000 words on your chosen field and your aspirations in contributing to the financial services landscape and the country in general. [Please use separate sheets of papers if the column provided is not sufficient]

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SECTION REFEREES Please provide names, addresses, occupations and contact nos. of two (2) referees who are not related G

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Referee 1: Name as per NRIC Residential Address : : : House Tel. No. NRIC No. Referee 2: Name as per NRIC Residential Address : : : : : Mobile No. Email Address : :

House Tel No. NRIC No.

: :

Mobile No. Email Address

: :

I, _______________________________________________, I/C No. _________________________________ do hereby certify that all information provided in this application are true and accurate to the best of my knowledge and have not withheld any material information which might influence the consideration of this application. I understand that any misrepresentation/false declaration or omission will result in cancellation or withdrawal of any scholarship awarded. I also authorise any investigation of the above information for the purposes of verification.

__________________________________________ Applicants Signature

___________________________________ Date

FOR OFFICE USE ONLY Date Application Received & Received by Shortlisted for interview Comments:: Yes No

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CHECKLIST
Please ensure all the documents listed below are included in your scholarship application submission:Completed application form Certified true copy of National Registration Identification Card (Both Sides on A4 paper) Certified true copy of Sijil Pelajaran Malaysia transcript Certified true copy of applicants/parents/guardians most recent EA/BE Form/Payslips Tax Return Form /any other proof of income 1000 word essay Recent passport-sized colour photograph Acceptance/Offer Letter by University or private college to undertake a field of study as approved by PIDM PIDM accepts documents that are certified by any of the following individual:1. Grade A Government Officer 2. School Principal/Headmaster 3. Commissioner of Oath 4. Ketua Kampung 5. Ahli Jawatankuasa Kemajuan dan Keselamatan Kampung

6. The employer or authorised representative of the employer

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