IIUM/STADD/01/

Workstation: WELFARE
Version No.: 02
Revision No.: 00
Date: 01/05/2015

Verification by :
.
Name :
Date :

photo

STUDENT AFFAIRS AND DEVELOPMENT DIVISION

INTERNATIONAL ISLAMIC UNIVERSITY MALAYSIA
KHAIRAT / FINANCIAL ASSISTANCE FORM

1.

Name : ........

2.

........

Course : ....
Year of Study : ... CGPA : GPA : ...

3.

Matric No : .........

4.

I/C No. / Passport No. : ......

5.

Marital Status : ......

6.

Country of Origin : ......

7.

Sponsorship / Loan : .........

8.

Banks Account No : .......

9.

Last payment received & amount : ...........

Bank : Islam / Muamalat / Others : ...

Mahallah & Room No : .......

10. E-mail Address : ..

11. Applicant Contact No. / HP No. : ........

12. Postal Address : ..
....
13. Reasons for Applying : ......
. (Please attach additional document if necessary)
14. Amount Applied : RM ......
15. Parents / Spouse / Guardian Information :
Particular

Father

Mother

Spouse / Guardian

Name
Contact No.
Age
Occupation
Monthly Gross Income (RM)
Health Condition

16. Home Address : ...

...

17. Sibling / Relatives Information :

Relation
(Brother/
Sister/Others

Name

Age

Occupation

Marital
Status

Income /
Expenditure
(RM)

Kindly fill in the details about your siblings and family (if unmarried) or children (if married) living under the same roof.
(Please attach additional document if necessary)

18. Have you applied for Khairat / Financial Assistance before?

Yes

Never

19. If yes, please fill in the details below :

Year :

Amount Received : RM ....

Reason : ...

20. Students Declaration

I in the name of Allah, hereby declare that all information given in this form is true and correct to the best of
my knowledge. I understand should there be any false information, my application will be rejected and any decision
made by the committee is final.

Signature : ..

Date :

Comment / Recommendation from Principal of Mahallah

..
......
Name : .....

Amount Recommended : .

Signature / Official Stamp : ..

Date : ..

*for Living Off Campus student: Comment / Recommendation from Deputy Dean (Student Affairs) of the
respective Kulliyyah.

Comment from Director / Assistant Director Office of International Affairs (for International Students Only)
..
......
Name : ...

Date : ...

Signature / Official Stamp : ..

FOR OFFICE USE

Approved / Not Approved : RM ....
Remarks : ...
Date : ...

...
Chairman
Khairat Fund Committee Meeting No. : .....

Important Notice
Please submit the following documents to support your application :
Latest Result Slip

Bank Statement / Copy of Bank Book

Confirmation Slip

Death Certificate (for Death Cases)

Financial Statement

Police Report (for Theft Cases Outside the Campus)

Parents Salary Slip

Security Report (for Theft Cases Within Campus)