Universiti Tunku Abdul Rahman

Form Title: SCHOLARSHIP APPLICATION FORM

Form Number : FM-DEAS-205 Rev No : 0 Effective Date: 14/06/2013 Page No : 1 of 4

UNIVERSITI TUNKU ABDUL RAHMAN Recent

SILVERLAKE SCHOLARSHIP APPLICATION FORM Photo

SECTION A – PERSONAL INFORMATION

1. Name:_________________________________________________________NRIC No:__________________________________
(as in NRIC)
2. Faculty:_______________________________________ Programme:_________________________________ Sex: Male/Female*

3. Intake Year (e.g. May 2011) ________________________________ Student Reg. No: __________________________________

4. Date & Place of Birth:_____________________________________________________ Nationality:________________________

5. Home Address: ______________________________________ 6. Correspondence Address:____________________________

___________________________________________________ _________________________________________________

___________________________Tel. No:__________________ ____________________________Tel. No:______________

E-mail:______________________________________________ Handphone No:____________________________________

SECTION B – ACADEMIC AND EXTRA-CURRICULAR INFORMATION

7. Certified true copies of Examination Result:- Secondary/ College Certificate/ Diploma/ University Degree MUST be attached.

8. Have you ever received any academic award or Book Prizes? If so, describe (with dates and amount).
________________________________________________________________________________________________________

9. List all participation in extra-curricular activities in previous schools/college and University and position held. **
________________________________________________________________________________________________________

_______________________________________________________________________________________________________

SECTION C – FAMILY INFORMATION

10. Details of Parents’/ Guardian’s financial circumstances (supporting documents must be provided):
Single/Married/ Income From
Monthly
Name Age Occupation Separated/Divorced/ Other Sources
Income (RM)
Widowed (RM)
Father

Mother

Guardian

11. Details of sibling(s):

If working If studying
Monthly Name of
Name Relationship Age Occupation Income Level School/ Institution/
(RM) College/ University

*Delete whichever not applicable

** If there is insufficient space in this form, please attach additional sheets of paper
 Universiti Tunku Abdul Rahman
Form Title: SCHOLARSHIP APPLICATION FORM
Form Number : FM-DEAS-205 Rev No : 0 Effective Date: 14/06/2013 Page No : 2 of 4

SECTION D – FINANCIAL INFORMATION

12. List sources of financial support for your studies in the University and indicate amount:
Source(s) Amount (RM)

13. Do your parents own a house? Yes / No*. If yes, specify type and address e.g. double-storey, etc.
_______________________________________________________________________________________________________

14. Have you APPLIED to any other source for financial assistance for the current year?
Please circle appropriately: 1. YES 2. NO
If Yes, specify: ___________________________________________________________________________________________
_______________________________________________________________________________________________________
(State name of scholarship/ loan/ award and when applied)

15. Have you ever been AWARDED any bursary, scholarship/ loan or financial assistance from the University or any government or
other sources? Please circle appropriately: 1. YES 2. NO

If Yes, specify: ___________________________________________________________________________________________

_______________________________________________________________________________________________________
(State name of scholarship/ loan/ award and when awarded)

SECTION E - OTHERS

16. If you were unsuccessful in obtaining a scholarship from the University, how do you propose to finance your studies?**
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

17. State any other facts / information in support of your application.**

_______________________________________________________________________________________________________

18. State if you have any criminal records.

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

SECTION F – REFEREES

19. Names and addresses of two referees, from whom information about you may be obtained. Please refer to Information for
Making Application for UTAR Scholarship attached.

i) Name:________________________________________ ii) Name:__________________________________________

Relationship:__________________________________ Relationship: ___________________________________
Occupation:___________________________________ Occupation:_____________________________________
Address:______________________________________ Address: _______________________________________
______________________________________________ ______________________________________________
Tel. No:________________________________________ Tel. No: ________________________________________

SECTION G – DECLARATION BY STUDENT

20. I affirm that the above information is complete, true and correct, and understand that if I am offered the scholarship, the University
reserves the right to withdraw the offer when at any stage, it is found that the information given is incorrect or if, in the opinion of
the University, I have failed to make satisfactory progress in my studies or disciplinary action has been taken against me by the
University.

Date:_________________________________ ________________________________
Signature of Applicant

INCOMPLETE APPLICATION FORM WILL NOT BE PROCESSED!

*Delete whichever not applicable

** If there is insufficient space in this form, please attach additional sheets of paper
 Universiti Tunku Abdul Rahman
Form Title: SCHOLARSHIP APPLICATION FORM
Form Number : FM-DEAS-205 Rev No : 0 Effective Date: 14/06/2013 Page No : 3 of 4

SECTION H – CHECKLIST FOR APPLICANT

One (1) recent passport size photo

One (1) certified true copy of NRIC

Certified true copy of examination results (e.g. Secondary/ College Certificate/ Diploma/ University Degree)

Latest certified true copy of University examination results, if any

Certified true copies of letters/certificates/testimonials of participation/achievement in extra-curricular activities

Certified true copies of UTAR offer letter and student bill, if any

Others

SECTION I – FOR OFFICE USE

Date Received: Complete and Processed: Incomplete:

□ One (1) recent passport size photo
□ One (1) certified true copy of NRIC
□ Certified true copy of examination results (e.g. Secondary/ College
Certificate/ Diploma/ University Degree)
□ Latest certified true copy of University examination results, if any.
□ Certified true copies of letters/ certificates/ testimonials of
participation/achievement in extra-curricular activities
□ Certified true copies of UTAR offer letter and student bill, if any
□ Others
Name of Staff-in-charge: Date:

Remarks:
 Universiti Tunku Abdul Rahman
Form Title: SCHOLARSHIP APPLICATION FORM
Form Number : FM-DEAS-205 Rev No : 0 Effective Date: 14/06/2013 Page No : 4 of 4

UNIVERSITI TUNKU ABDUL RAHMAN

SILVERLAKE SCHOLARSHIP APPLICATION
___________________________________________________________________________________
Information for Making Application for UTAR Scholarship
(Please read the following information before you complete the application form.)
I. Application Form

The student should complete 1 set of Scholarship Application Form, and enclose the following
documents:

1. One (1) recent passport size photo;

2. One (1) certified true copy of NRIC;
3. Certified true copies of examination results (e.g. Secondary/ College Certificate/ Diploma/
University Degree);
4. Latest certified true copy of University examination results, if any;
5. Certified true copies of Letters/Certificates/Testimonials of participation/achievement in extra
curricular activities;
6. Certified true copies of UTAR offer letter and student bill, if any.

II. Referees

Names of referees are required to be given by each applicant. One should be an academic
reference who is able to comment on the applicant’s academic abilities while the other should be
able to comment on the applicant’s financial circumstances.

Referees should preferably not be related to the applicant but are able to provide information on the
applicant. Names of referees who are fellow students or students from other institutions will
not be accepted.

III. Submission of Application

Completed application form must be returned to the Division of Examinations, Awards and
Scholarships.

IV. Application Status Enquiry

For enquiry on the status of application, please refer to Division of Examinations, Awards and
Scholarships.

The application form must be completed in the applicant’s own handwriting.

INCOMPLETE Application Form will NOT be PROCESSED!

Only successful applicants will be notified.