DANA PIBG APPLICATION FORM (PARENT-TEACHER ASSOCIATION FUND)

SECTION A: APPLICANT INFORMATION Name:

NRIC No:

Position in PIBG:

Home/Office Phone No:

Mobile No:

Mailing Address:

Postcode:

Email Address:

SECTION B: SCHOOL INFORMATION Number of Students: Number of Teachers: Type of School:

School Name:

Email Address (If any): Website (If any):

Phone No: Fax No: 1

School Address:

Postcode:

Name of Headmaster / Principal:

Office Phone No:

Mobile No:

SECTION C: APPLIED FUND INFORMATION 1. Information on Activities or Programs Application Category (Mark "X" in the relevant box):

Name of activities or programs:

The objective of activities or programs:

Benefits or impacts of activities or programs:

Duration: (Month)

Number of students involved in activities or programs:

Amount of funds requested (RM):

Reminder: Max amount allowed for Secondary School Max amount allowed for Primary School :RM 50,000 :RM 30,000

Details breakdown of expenditure for funds requested:

If the space provided is insufficient, please insert attachment.

2. Information of Activity or Program Manager (If other than applicant) Name:

NRIC:

Status:

Office/Home Phone No:

Mobile No:

Email Address:

SECTION D: DOCUMENTS THAT MUST BE ATTACHED

Note: 1) Apart from the required documents, applicants may attach other supporting documents, if any, to support this application. 2) All documents must be verified by Yang DiPertua PIBG.

SECTION E: PIBG BANK ACCOUNT INFORMATION Name of Bank Account:

Bank Account No:

Bank Name:

Bank Branch Address:

DECLARATION
I, _____________________________________________________________ (Name of Applicant) on behalf of _________________________________________________________ (Name of School PIBG) hereby certify that the information given in this return and accompanying document is true, correct and complete. I understand the conditions of application of the Dana PIBG and understand that this application may be disqualified if the information provided is false.

Applicant Signature Name NRIC Date

: : : :

Verified by;

Yang DiPertua PIBG Signature Name NRIC Date : : : :

Headmaster / Principal Signature Name NRIC Date : : : :

Please read the following reminder before signing. This is to ensure that the application submitted is complete.

REMINDER
Please make sure that you have filled in the return form completely and in order. Please check all the details carefully before submitting them. Applications that are not complete, will NOT be entertained by the Yayasan 1MDB. Only one application can be made in any one time. Make sure the following items have been done (Mark X in appropriate box): Fill in all the details required. Applications must be from PIBG of Government School or Government-Aided Schools throughout Malaysia. Applicants must be a PIBG committee from the school. Bank account information must be the name of the school PIBG ONLY. Get all the copies of documents that MUST be attached and verified by Yang DiPertua PIBG. If applicable, kindly translate your documents to Bahasa Malaysia or English if your documents are in other languages.

Applications can be submitted through the following channels: 1) Mail it to: Dana PIBG 1Malaysia, Level 8, Menara IMC, No 8, Jalan Sultan Ismail, 50250 Kuala Lumpur Malaysia 2) Email to danapibg@1mdb.com.my

Office Use: Date Received Received By : :