ASIAN NURSING SCHOLARSHIP COUNTRY: MALAYSIA

– APPLICATION FORM
Supporting documents required:
(1) Identity Card and Singapore NRIC if you are a Singapore PR
(2) Sijil Pelajaran Malaysia (SPM) / Unified Examinations Certificate (UEC) / IGCSE / GCE ‘O’ Level Certificate
and transcripts

Please complete the application form in BLUE ink. Please circle for items with asterisk (*)

A. PERSONAL PARTICULARS Please affix a

recent
Full Name (as in Identity Card) Underline Surname Marital Status *Gender
Passport-sized
TAY WEN XUAN Male / Female
photograph
SINGLE
(white
Alias/Other Name (if any) Name in Chinese Character (if applicable)
background)
NA 郑文宣
Home Address / Residential Address Identity Card No. *Singapore PR
No 43, Jalan 3/20, Taman Sri Kluang, 040410-01-1316
Yes / No
Postal Code: 86000
Home Telephone No. Mobile No. Email Address

NA 013-8030410 taywenxuan87@gmail.com
Nationality Country of Birth Date of Birth (dd-mmm-yyyy) e.g. 01-Jan-1990 Age

MALAYSIAN MALAYSIA 10-APR-2004 18

Religion Languages Spoken Languages Written

BUDDHIST CHINESE, ENGLISH CHINESE, ENGLISH

B. EMERGENCY CONTACT DETAILS
Full Name Relationship Home Telephone No.

Mobile No.
LEOW SEI WEI DAUGHTER & MUM +65 91520273
C. PARTICULARS OF IMMEDIATE FAMILY (please attach a separate sheet if there are more family members)
Name of family members Age Relationship Occupation Contact number Company / School Name and Country
of Workplace / School

YISHAN WELLNESS PTE LTD

Father SALES CONSULTANT
TAY CHUAN SIONG 46 +65 94673571
SINGAPORE
ENG CHOON PTE LTD
Mother
LEOW SEI WEI 47 DESSERT MAKER +65 91520273 SINGAPORE

YISHAN WELLNESS PTE LTD

* Brother/Sister HUMAN RESOURCE
TAY WEN FENG 22 EXECUTIVE +65 82186515 SINGAPORE
HOCK HUA TONIC PTE LTD
* Brother/Sister
TAY MING JUN 19 SALES ASSISTANT +65 96286515 SINGAPORE

KLUANG CHONG HWA HIGH SCHOOL

* Brother/Sister
TAY MING ZHONG 14 STUDENT +601126752678
MALAYSIA

* Brother/Sister

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D. EDUCATION
1) Sijil Persekolahan Malaysia (SPM) / Unified Examinations Certificate (UEC) / IGCSE / GCE ‘O’ Level examination results
2) Past 2 years Secondary School (Form 3 & 4) examination results
Please list your scores/aggregates :

Two other best subjects

Name of Science
Standard Year English Maths Science Subject Subj 1 Subj 1 Subj 2 Subj 2
(in English) scores Name scores Name
(in English) (in English)

MALAY LANGUAGE
SENIOR 3 2022 80 55 58 BIOLOGY 81 HISTORY 80
SPM 2021 C D B+ SCIENCE B+ HISTORY B CHINESE LANGUAGE

SENIOR 2 2021 HISTORY 79 CHINESE LANGUAGE

72 54 77 BIOLOGY 84
SENIOR 1 2020 58 68 75 BIOLOGY 92 HISTORY 84 MALAY LANGUAGE

E. MEDICAL DECLARATION
Note: Any willfully incorrect or misleading statement or omission may lead to withdrawal of ANS Scholarship if selected
1) Have you ever suffered from or have been treated for any of the following illnesses? ( Please circle )
a. Hepatitis B/ C / E Yes No
b. Measles Yes No
c. Mumps Yes No
d. Rubella Yes No

e. Chickenpox AT YEAR 2005 Yes No

f. Tuberculosis Yes No
g. Asthma Yes No
h. Migraine / Severe Headache Yes No
i. High Blood Pressure Yes No
j. Blood disorder Yes No
k. Severe Anemia Yes No
l. Diabetes Yes No
m. Skin Disease (e.g. Psoriasis, Chronic Eczema) Yes No
n. Breast Lumps Yes No
o. Epilepsy / Fits Yes No
p. Syncope / Frequent Fainting Spells Yes No
q. Hearing Impairment Yes No
r. Chronic Ear Discharge/Disease Yes No

s. Vision Problems / Colour blindness SHORTSIGHTED Yes No

t. Mental Illness or Nervous Breakdown Yes No
u. Psychiatric Conditions (Depression, Psychosis, Anxiety disorder, etc) Yes No
v. Cancer / Tumor Yes No
w. Eating Disorders Yes No
x. Heart Disease Yes No
y. Kidney Disease Yes No
z. Frequent gastric pain / Gastric Problem Yes No
aa. Backache Yes No

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 (Please circle)
bb. Joint pains or discomfort (Head/Neck, Shoulder/Arm/Hand, Waist/Back, Lower Limb etc) Yes No
cc. Physical disabilities e.g. loss of fingers Yes No
dd. Impaired health / function due to accident or injury Yes No
ee. AIDS / HIV Positive Yes No
ff. Infectious Disease (e.g. Malaria, Typhoid etc) Yes No
gg. Any Congenital Disease / abnormalities / birth defects (e.g. Atrial septal defect, Ventricular septal
Yes No
defect, Mitral valve prolapse etc)
hh. Are you on long-term medication? Yes No
ii. Any other diseases, impairment or injury, etc.? Yes No
jj. Have you been hospitalized or underwent any surgery? Yes No
kk. Any other significant medical condition/history not otherwise listed above?
Yes No
(e.g. Scoliosis, Sweaty palms etc)
If YES for any of the above, please give details including date, period/duration, treatment received, and status to date.

2) Allergy History in (Please circle)

a. Drug Allergies (Medication / Injection) Yes No
b. Skin Cream / Lotion Yes No
c. Food Yes No
d. Chronic Allergic Conditions e.g. rhinitis Yes No
e. Others: e.g. nickel / rubber gloves / Latex / Chlorhexidine, Alcohol-based solutions, Others etc) Yes No
If Yes, please give details of allergy:

3) Have you ever been found unfit in any previous medical examination (Please circle)
a. Pre-employment Yes No
b. National service Yes No
c. Life insurance Yes No
4) Do you have any Body Art (Tattoo)? (Please circle)
If yes, please state location(s):
Yes No

5) FEMALES ONLY (Please circle)

a. Pregnant Yes No
b. Gynecological disorder Yes No
c. Abortion Yes No
F. OTHER INFORMATION
1) Have you ever been convicted in a court of law in any country?
If Yes, please give details:
Yes No

2) Have you applied for Asian Nursing Scholarship previously?

If Yes, please indicate the year you have applied:
Yes No

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3) Do you have any siblings currently applying/taking Asian Nursing Scholarship?
If Yes, please indicate your sibling name, and the year he/she started the nursing course if he/she is
currently an ANS scholar
Yes No

4) Record of Academic Achievements (eg representative in national Olympiad Mathematics Competition):

take part in International Chemistry Quiz(ICQ)

5) Record of Achievements in Extra Curricular Activities:

Basketball Competition runner-up
Basketball Competition champion

G. DECLARATION
I understand that any false statement made by me on this application or any supplement thereto will be sufficient for disqualification or
dismissal if appointed. The willful suppression of any material fact will be similarly penalised.

28/09/2022
Signature of Applicant Date

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