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APPLICATION FORM

(Important Note: Please read the instruction on page 4 prior to completing this form)

Section 1: PERSONAL DETAILS


Full Name (Mr. / Mrs. / Miss):

IC / Pasport Number:
Sex: (M/F)

Nationality:

Marital Status:

Date of Birth:

Race:

Age:

Religion:

please affix a pasport-sized


photo

Correspondence Address:

Poscode :

State :

Tel Number :

Permanent Address (if different from the above):

Poscode :

State :

Tel Number :

Guardian's name (if other than parents):

Guardian's Occupation:

Guardian's Address:

Poscode :

State :

Tel Number :

Section 2: PROGRAMME OF STUDY


Name of Programme:
Centre of Study:
Intake (Month / Year):

Duration (semesters):

Section 3: ACADEMIC QUALIFICATIONS


(Please submit certified copies of relevant certificates)

a) Schools / Colleges / Universities attended and qualification achieved


Qualification Completed

Schools / Institutions

Year

City / State

PMR
SPM / SPVM / O Level
STPM / A Level / Matriculation
Others (Please specify) :

b) Scholarship / Study Loan Or Sponsorship received


Type of Scholarship / Loan

Agency

Year

Duration

Section 4: CO CURRICULAR & OTHER ACTIVITIES


Please state membership / post held in any society or involvements in sports (club / district / state / national level):

Section 5: FAMILY BACKGROUND


Please submit certified copies of J Form or a certified Statement of Income (for self-employed parents)

Details
Full Name
IC No.

Permanent Address

Correspondent Address

Place & Date of Birth


Nationality
Religion
Race
Occupation

Employer & Address

Employer's Tel. No.


Salary / Month (RM)
Other source of income (RM)

Date Retire / Decease


(if applicable)

Father

Mother

Section 6: SIBLINGS
No.

Name

Age

Occupation / School

1
2
3
4
5
6
7
8
9
10

DECLARATION BY APPLICANT
I declare that the information provided in connection with this application is true and correct. I understand that
MSU reserves the right to vary or reverse any decision regarding this scholarship on the basis of
incomplete information.

Applicant's signature

Date: _______________________________

FOR OFFICE USE ONLY


The application is:

Type of scholarship awarded:

Remark:

successfull

unsuccessfull

NOTES AND INSTRUCTIONS


This application form must be fully completed. Please type or write in black or blue pen or ball-point pen using
BLOCK LETTERS.
1

All applicants must write their full name exactly as per identity card or 'Resit Pengenalan Sementara' (JPN 1/9) or
or 'Resit Penukaran Kad Pengenalan' (JPN 1/22) issued under the National Registration Act (1959) where applicable.

A legible photocopy of the idendity card or 'Resit Pengenalan Sementara' or ' Resit Penukaran Kad Pengenalan'
must be enclosed togetherwith Application Form.

Form defaced by erasure or any kind of correcting fluids may results in the application being not be accepted at the
descretion of MSU. Every amendment must be clear and legible and should be countersigned in full by applicant.

Each completed application form must be accompanied by certified and clear copies of relevant documents
eg) certified transcripts, parents' payslip (or declaration of income)

MSU reserves the right to require any applicant to appear in person before MSU management to ascertain
the genuineness of the information provided by the application form submitted.

MSU shall not be liable to return the submitted application form or any document/s and/or transcripts attached.
Applicants should not send original copies of the documents.

MSU reserves the right to reject/withdraw any application which do not confirm to the above
instructions or which are illegible or which are accompanied by remittance/s improperly drawn.

Completed form must be returned to :

The Secretariat,
Scholarship Unit - Yayasan MSU,
University Drive,
Off Persiaran Olahraga,
Seksyen 13,
40100 Shah Alam.
(attn: Dato' Sharifah Huda Engku Muda)