PIDM 2013 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 26 April 2013 to:Human Capital Division (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 Date of Birth : : : :

PERSONAL DETAIL
JAS KHAIRULSHAZWAN BIN JAS SARIPUDEEN NO.41A LORONG PANDAMARAN JAYA 100, PANDAMARAN JAYA, 42000, PELABUHAN KLANG, SELANGOR. 0133977455 951119105779 MALAYSIAN 19/11/1995 Mobile No. Email Address Gender : : : 0197869138 jaskhairulshazwan@gmail.co m MALE

SECTION B
N O
PIDM SAF2013

UNIVERSITIES AND FIELD OF STUDIES

COURSES UNIVERSITIES

Page 1

1. 2. 3.

ASASI SAINS HAYAT ASASI KEJURUTERAAN DAN SAINS KOMPUTER ASASI KEJURUTEAAN

UNIVERSITI MALAYA(UM) UNIVERSITI ISLAM ANTARABANGSA MALAYSIA(UIAM) UNIVERSITI TEKNOLOGI MARA (UITM)

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 . SUBJECT BAHASA MELAYU BAHASA INGGERIS PENDIDIKAN ISLAM SEJARAH MATHEMATICS ADDITIONAL MATHEMATICS PHYSICS CHEMISTRY BIOLOGY TASAWWUR ISLAM GRADE A AA+ A A+ A AB+ AA+ N O 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. SUBJECT GRADE : : HULU SELANGOR SCIENCE SCHOOL 2012 Final Grade : SPM

STPM or Matriculation or A Level or equivalent: Name of School Year Completed Detailed Grade:
PIDM SAF2013 Page 2

: :

NA NA Final Grade : NA

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

SUBJECT

GRADE

N O 6. 7. 8. 9. 10.

SUBJECT

GRADE

Other Qualifications or Awards Received

N O
1. 2.

NAME OF QUALIFICATION OR AWARD RECEIVED

WIRA TERBAIK KEM PLKN GAMBANG KUMP. 1/ SIRI 10/ TAHUN 2013 OLAHRAGAWAN SEKOLAH

AWARDED BY
JABATAN LATIHAN KHIDMAT NEGARA SEKOLAH MENENGAH SAINS HULU SELANGOR

DATE OF AWARD
16/3/2013

3. 4. 5. Extra Curricular Activities N O NAME OF SOCIETIES / CLUBS / SPORTS / OTHER ACTIVITIES POSITION HELD YEAR

SECTION D
Legal Guardian, where applicable Fathers Name
PIDM SAF2013

FAMILY & INCOME DETAILS

: Mothers Name :
Page 3

Age NRIC No. Occupation Name of Employer Address of Employer

: : : : :

Age NRIC No. Occupation 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]

PIDM SAF2013

Page 4

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)

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

PIDM SAF2013

Page 5

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]

PIDM SAF2013

Page 6

PIDM SAF2013

Page 7

SECTION Please provide names, addresses, occupations andREFEREES contact nos. of two (2) referees who are not G
PIDM SAF2013 Page 8

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:PIDM SAF2013 Page 9

: Yes No

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

PIDM SAF2013

Page 10