Académique Documents
Professionnel Documents
Culture Documents
App No.
FORM CS-01
Please return your completed application form to the following address before the closing date for application: UBD Chancellors Scholar Secretariat
Administration Building
Universiti Brunei Darussalam
Jalan Tungku Link
Gadong BE1410
Brunei Darussalam
www.ubd.edu.bn
Tel: +673-2463001 Ext 1160/1900/1653
Fax: +673-2460757
Email: chancellor.scholarship@ubd.edu.bn
Website: http://www.ubd.edu.bn
You are required to submit one set of the completed application. Each application includes: 1. Completed application form (CS-01)
2. Two recent passport-sized photographs
3. Supporting documents as per checklist at the end of this application form
NOTE: Certified English translations must be submitted for supporting documents that are not in the English Language. Online application is currently
not available.
____________________________________________________________________________________
IC No. _______ -__________________
Colour ________________________
Nationality ______________________
Birthplace _____________________
Age________
(dd/mm/yy)
Religion ________________________
Domicile ________________________________________
(Country you live in permanently)
Passport No. _____________ Place of Issue _____________ Date of Isssue __________ Date of Expiry _______________
(dd/mm/yy)
(dd/mm/yy)
____________________ Home
____________________Mobile
____________________ Fax*
___________________________________________________________________________________________________________
Other Contact No(s) ______________________________
Email* __________________________________________
*Applicants are strongly advised to provide either a fax no. or an e-mail address to facilitate correspondence)
UBD Chancellors Scholarship
FAMILY INFORMATION
Name of Parent / Guardian ______________________________________________________________________________________
Male Female
(As in Identity Card)
IC No. _______ -__________________ Colour ________________________ Ethnic Group _______________________
Occupation __________________________________
Appointment __________________________________________
Employer __________________________________________________________________________________________
Mailing Address _____________________________________________________________________________________
__________________________________________________________________________________________________
Contact No(s) ________________ Home
_________________ Mobile
____________________ Office
Fax ____________________________
Email ____________________________________________
Appointment __________________________________________
Employer __________________________________________________________________________________________
Mailing Address _____________________________________________________________________________________
__________________________________________________________________________________________________
Contact No(s) ________________ Home
_________________ Mobile
____________________ Office
Fax ____________________________
Email ____________________________________________
Have any of your family members received the UBD Chancellors Scholarship or from Ministry of Education Goverment Scholarship in
the past?
Yes
No
If yes, please list their names, relationship to you and year of award.
1.
______________________________________________________________________________________________________
2.
______________________________________________________________________________________________________
3.
______________________________________________________________________________________________________
Yes
No
If yes, please list their names, rank, current posts and their relationship to you.
1.
______________________________________________________________________________________________________
2.
______________________________________________________________________________________________________
3.
______________________________________________________________________________________________________
EDUCATIONAL BACKGROUND
Please indicate Examining Board where appropriate, e.g. Cambridge Examination Board / London Examination Board / International
Baccalaureate and/or Equivalent. Please submit official true copies results / transcripts.
First / Masters Degree
University ___________________________________________________________________________________________________
Address ______________________________________________________________________________________________________
_____________________________________________________________ Contact No. _____________________________________
Fax _____________________________
Email ____________________________________________________________________
Date
Subject
(mm/yyyy)
(mm/yyyy)
Semester
Numerical and/or
Level Grade
Email ____________________________________________________________________
Date
Subject
(mm/yyyy)
(mm/yyyy)
Examining Board
Level
(A/AS)
Numerical and/or
Level Grade
To
(dd/mm/yyyy)
(dd/mm/yyyy)
E.g. 01/01/2000
07/01/2000
Grade
Informatics (Singapore)
NETWORK + (C)
Pass
Award
Awarded by
(mm/yyyy)
Office /
Position Held
Elected /
Appointed /
Voluntary
Level (School /
District /
National)
Active Dates
(dd/mm/yy)
WORK EXPERIENCE
List your current and/or most recent position (if any).
Position ______________________________________________
Organisation _________________________________________
Date Employed (From) _______________________ (To) ______________________________ Part Time / Full Time
(dd/mm/yy)
(dd/mm/yy)
Government Non-Profit
Private Sector
VOLUNTARY SERVICE
List your current and/or most recent position (if any).
Position ______________________________________________
Organisation _________________________________________
(dd/mm/yy)
Government Non-Profit
Private Sector
Course of Study
University Location
Application
Submitted
Outcome of
Applciation
E.g.
Poticial Science
YN
Awaiting Reply
YN
YN
YN
YN
YN
YN
YN
YN
No
PREVIOUS APPLICATION
Have you previously applied for this Scholarship before?
Yes
No
___________________________
Reading Score
___________________________
Total Score
___________________________
____________________
Math Score
___________________________
Writing Score
___________________________
Total Score
___________________________
________________________
________________________
________________________
________________________
REFERENCES
Please provide the details of at least 2 referees below. Referee reports are to be completed by your Dean, Lecturer and/or
Club/Organisation Leader. The Referees report must be submitted in a sealed envelope with the referees signature across the flap of
the envelope.
Name ____________________________________________________
Position ___________________________________
Email _______________________________________________________________________________________________
Name ____________________________________________________
Position ___________________________________
Email _______________________________________________________________________________________________
Name ____________________________________________________
Position ___________________________________
Email _______________________________________________________________________________________________
DECLARATION
Have you ever been convicted by a Court of law of any country?
Yes
No
I hereby declare that the information provided in this application is correct and the attachments are true to the best of my knowledge
and belief, and I have not witfully suppressed any material fact. I authorise Universiti Brunei Darussalam to obtain official records, if
necessary, from any educational institution I have attended.
As far as I am aware, I am medically fit and free from any medical problem which may impair my ability to attend to my studies.
I understand that any provision of inaccurate and false information or omission of information will render this applciation invalid and
that, if admitted on the basis of such information, I can be required to withdraw from the Scholarship.
Signature _____________________________________
Date ___________________________
Date Received:
Application No:
10
ATTACHMENT 1 ESSAY
Please note that the essay is an important part of your Scholarship application. Please attach (not staple) a typed or computergenerated copy in thte space below. We strongly prefer that you do not handwrite your responses.
Write a short essay on who you are and what you are passionate about (400-500 words). The essay has to be an original piece, and no
part of it may be copied.
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CONFIDENTIAL
ATTACHMENT 2 FACULTY DEAN REFERENCE FORM
TO THE APPLICANT
Please fill in the personal information below and forward this form to your current or previous Faculty Dean. Each reference must be
put in a sealed envelope, signed across the seal by the referee and returned to you by submission with your scholarship application
package.
PERSONAL INFORMATION
Name Mr / Miss _________________________________________________________________
(As in Identity Card)
_________________ Mobile
____________________ Office
Relevant factual data about the applicants academic performance and elevel fo extra-curricular achievement;
Your impressions of the candidates personal qualities and contribution to your school community; and
Information about personal circumstances that might have disadvantaged the applicant.
If you prefer to send a letter or statement (on the Universitys / Institutions letterhead and/or stamped), please feel free to do so.
Please check the rating boxes and include your letter or statement with this form and return both to Scholarship Office, Universiti
Brunei Darussalam. We appreciate the effort you expend on behalf of your student applying for this scholarship.
Name of person completing this report _____________________________________________________________________________
Position ___________________________________ University / Institution _______________________________________________
Contact No ___________________
Fax _____________________
Signature _________________________________
Email ________________________________________
Date _______________________________________________
Others ____________________________________________________________________________________
12
TRANSCRIPT Please include an official copy of the applicants transcript of work completed from their Undergraduate (or the
equivalent). A brief explanation of titles or unusual grading systems would greatly assist us in assuring an accurate assessment of the
applicants level of achievement.
1.
ACADEMIC / INTELLECTUAL
In what way might you distinguish this applicants academic performance from that of other university-bound students?
Either through personal experience or in talking with lecturers, how would you characterise this applicants level of
intellectual curiosity and approach to learning?
2.
PERSONAL / INTERPERSONAL
a. What do you like best about this applicant? In what ways has this applicant made an impact either in your University/
Institution or in the community?
b.
3.
Are there any factors that might interefere with teh applicants academic performance and/or personal relationship
during his/her couorse of study
ADDITIONAL INFORMATION
a. Is there anything else we should know about this applicant (e.g. personal circumstances, character, values, a point of
interest or concern, particular interests, unusual accomplishments / special talents, obstacles overcame?)
Yes (Please explain fully on a separate sheet)
No
b.
c.
Has the applicant ever violated an Honour Code or been placed on provation, suspended or expelled from your
institution?
13
4.
CHECKLIST
Rate the applciant in the checklist below. We are interested in your comparison of the applicant to other university-bound
students at the same level in your university / institution.
No Basis for
Judgement
Marginal
(Lower 50%)
Average
(Top 50%)
Good
(Top 25%)
Excellent
(Top 10%)
Superior
(Top 3%)
Intellectual ability
Analytic frame of mind
Problem-solving orientation
Quality of oral expression
Sense of humour
Initiative
Intellectual Curiosity
Creativity
Motivation and Energy
Self-Confidence
Leadership / Influence
Integrity
Concern for others
Respect for differences
Warmth of personality
Ability to meet deadline
Emotion maturity
Reaction to setbacks
Respect accorded by faculty
Respect accorded by peers
If you wish to give reasons for any of your ratings, please attach additional sheets as required.
5.
SUMMARY
Based on your experience as Faculty Dean (for _________ years), how would you summarise the applicants promise as
compared to that of other university / institution bound students in your university?
Marginal
(Lower 50%)
Average
(Top 50%)
Good
(Top 25%)
Excellent
(Top 10%)
Superior
(Top 3%)
Academic
Personal
Overall
Taking into account that the minimum eligibility requirement is 3 Grade A in GCE A Levels / 5 Mumtaz in STPUB, I
recommend this student for Univeriti Brunei Darussalam Chancellors Schoalrship.
Not at all
With Reservation
Fairly Strongly
Strongly
Enthusiastically
14
CONFIDENTIAL
ATTACHMENT 3 LECTURER / SUPERVISOR REFERENCE FORM
TO THE APPLICANT
Please fill in the personal information below and forward this form to your current or previous Lecturer / Supervisor who knows you
well and has taught or sueprvised you in an academic subject eitehr this year or the year before and is able to comment about y ou.
Each reference must be put in a sealed envelope, signed across the seal by the referee and returned to you by submission with your
scholarship application package.
PERSONAL INFORMATION
Name Mr / Miss _________________________________________________________________
(As in Identity Card)
_________________ Mobile
____________________ Office
If you prefer to send a letter or statement (on the Universitys / Institutions letterhead and/or stamped), please feel free to do so.
Please check the rating boxes and include your letter or statement with this form and return both to Scholarship Office, Universiti
Brunei Darussalam. We appreciate the effort you expend on behalf of your student applying for this scholarship.
Name of person completing this report _____________________________________________________________________________
Position ___________________________________ University / Institution _______________________________________________
Contact No ___________________
Fax _____________________
Signature _________________________________
This report is based on (check all that apply):
Records
Email ________________________________________
Date _______________________________________________
Personal contact with student Lecturers Observation
Others ____________________________________________________________________________________
15
TRANSCRIPT Please include an official copy of the applicants transcript of work completed from their Undergraduate (or the
equivalent). A brief explanation of titles or unusual grading systems would greatly assist us in assuring an accurate assessment of the
applicants level of achievement.
1.
ACADEMIC / INTELLECTUAL
In what way might you distinguish this applicants academic performance from that of other qualified students? Please
comment on the students intellectual attitude, curiosity and enthusiasm for learning.
2.
Through which of the following does this applicant achieve academic success? (Check all that apply)
Hard work / diligence
Brilliance of mind
Love of learning
Other (Describe)
3.
PERSONAL / INTERPERSONAL
What do you like best about this student? In what ways has this student made an impact in your class, the school and/or in
the community? Are there any factors that might interfere with the students academic performance and/or personal
relationship during his/her couorse of study?
4.
ADDITIONAL INFORMATION
d. Is there anything else we should know about this applicant (e.g. personal circumstances, character, values, a point of
interest or concern, particular interests, unusual accomplishments / special talents, obstacles overcame?)
16
5.
CHECKLIST
Rate the applciant in the checklist below. We are interested in your comparison of the applicant to other university-bound
students at the same level in your university / institution.
No Basis for
Judgement
Marginal
(Lower 50%)
Average
(Top 50%)
Good
(Top 25%)
Excellent
(Top 10%)
Superior
(Top 3%)
Intellectual ability
Analytic frame of mind
Problem-solving orientation
Quality of oral expression
Sense of humour
Initiative
Intellectual Curiosity
Creativity
Motivation and Energy
Self-Confidence
Leadership / Influence
Integrity
Concern for others
Respect for differences
Warmth of personality
Ability to meet deadline
Emotion maturity
Reaction to setbacks
Respect accorded by faculty
Respect accorded by peers
If you wish to give reasons for any of your ratings, please attach additional sheets as required.
6.
SUMMARY
Based on your experience as Lecturer / Supervisor (for _________ years), how would you summarise the applicants promise
as compared to that of other university / institution bound students in your university?
Marginal
(Lower 50%)
Average
(Top 50%)
Good
(Top 25%)
Excellent
(Top 10%)
Superior
(Top 3%)
Academic
Personal
Overall
Taking into account that the minimum eligibility requirement is 3 Grade A in GCE A Levels / 5 Mumtaz in STPUB, I
recommend this student for Univeriti Brunei Darussalam Chancellors Schoalrship.
Not at all
With Reservation
Fairly Strongly
Strongly
Enthusiastically
17
CONFIDENTIAL
ATTACHMENT 4 CLUB / ORGANISATION LEADER REFERENCE FORM
TO THE APPLICANT
Please fill in the personal information below and forward this form to a club / organisation leader who knows you well and is able to
comment about y ou. Each reference must be put in a sealed envelope, signed across the seal by the referee and returned to you by
submission with your scholarship application package.
PERSONAL INFORMATION
Name Mr / Miss _________________________________________________________________
(As in Identity Card)
_________________ Mobile
____________________ Office
If you prefer to send a letter or statement (on the organisation/universitys letterhead and/or stamped), please feel free to do so.
Please check the rating boxes and include your letter or statement with this form and return both to Scholarship Office, Universiti
Brunei Darussalam. We appreciate the effort you expend on behalf of your student applying for this scholarship.
Name of person completing this report _____________________________________________________________________________
Position ___________________________________ Organisation _______________________________________________
Contact No ___________________
Fax _____________________
Signature _________________________________
This report is based on (check all that apply):
Email ________________________________________
Date _______________________________________________
Personal contact with student Records
Others _________________________________________________________________________________________________
How long have you known this applicant? ________________________________________________________________________
In what capacity? ___________________________________________________________________________________________
How often do you meet with this applicant? ______________________________________________________________________
How well do you know this applicant? ___________________________________________________________________________
18
TRANSCRIPT Please include an official copy of the applicants transcript of work completed from their Undergraduate (or the
equivalent). A brief explanation of titles or unusual grading systems would greatly assist us in assuring an accurate assessment of the
applicants level of achievement.
1.
ACADEMIC / INTELLECTUAL
In what way might you distinguish this applicants academic performance from that of other qualified students/members?
Please comment on the students intellectual attitude, curiosity and enthusiasm for learning.
2.
Through which of the following does this applicant achieve academic success? (Check all that apply)
Hard work / diligence
Brilliance of mind
Love of learning
Other (Describe)
3.
PERSONAL / INTERPERSONAL
What do you like best about this student/member? In what ways has this student/member made an impact in your club,
organisation and/or in the community? Are there any factors that might interfere with the students/members performance
and/or personal relationship during his/her couorse of study?
4.
ADDITIONAL INFORMATION
e. Is there anything else we should know about this applicant (e.g. personal circumstances, character, values, a point of
interest or concern, particular interests, unusual accomplishments / special talents, obstacles overcame?)
19
5.
CHECKLIST
Rate the applciant in the checklist below. We are interested in your comparison of the applicant to other university-bound
students at the same level in your university / institution.
No Basis for
Judgement
Marginal
(Lower 50%)
Average
(Top 50%)
Good
(Top 25%)
Excellent
(Top 10%)
Superior
(Top 3%)
Intellectual ability
Analytic frame of mind
Problem-solving orientation
Quality of oral expression
Sense of humour
Initiative
Intellectual Curiosity
Creativity
Motivation and Energy
Self-Confidence
Leadership / Influence
Integrity
Concern for others
Respect for differences
Warmth of personality
Ability to meet deadline
Emotion maturity
Reaction to setbacks
Respect accorded by faculty
Respect accorded by peers
If you wish to give reasons for any of your ratings, please attach additional sheets as required.
6.
SUMMARY
Based on your experience as Lecturer / Supervisor (for _________ years), how would you summarise the applicants promise
as compared to that of other university / institution bound students in your university?
Marginal
(Lower 50%)
Average
(Top 50%)
Good
(Top 25%)
Excellent
(Top 10%)
Superior
(Top 3%)
Academic
Personal
Overall
Taking into account that the minimum eligibility requirement is 3 Grade A in GCE A Levels / 5 Mumtaz in STPUB, I
recommend this student for Univeriti Brunei Darussalam Chancellors Schoalrship.
Not at all
With Reservation
Fairly Strongly
Strongly
Enthusiastically
20
CHECKLIST
Please check that you have enclosed the following application in your scholarship application package.
Completed application form (incomplete applications will not be processed).
2 recent passport size photographs of yourself.
Copy of IC.
Copy of Passport
Certified true copies of Transcripts / Certificiates (e.g. GCE A Level Examination result slips)
TOEFL / IELTS, SAT I and SAT II Scores (If not yet sat for, please provide date of candidature).
Co-curricular Activities (CCA) reports / certificates
Attachment 1 Application Essay.
Attachment 2 Faculty Dean Reference Report.
Attachment 3 Lecturer / Supervisor Reference
Attachment 4 Club / Organisation Leader Reference Report.
Copies of any other supporting documents (certified true copies, where relevant)
REMINDER
It is your responsibility to ensure that all application material is sent in time
to the Scholarship Office, Universiti Brunei Darussalam by the application
deadline. Early application is encouraged.
21