YAYASAN PROTON

(Company No. : 293586-D)

SCHOLARSHIP APPLICATION FORM

LATEST COLOUR PASSPORT SIZE PHOTO
FOR HR USE ONLY

APPLICATION NO DATE RECEIVED CATEGORY UNIVERSITY COURSE

CoS

EA

DF

A. PERSONAL PARTICULARS (MAKLUMAT PERIBADI) FULL NAME: DATE OF BIRTH: NATIONALITY: GENDER: AGE: CORRESPONDENCE ADDRESS: B. TERTIARY & SECONDARY EDUCATION SCHOOL i. ii. iii. HIGHESTQUALIFICATION/GRADES E-MAIL ADDRESS: MOBILE NO: HOUSE TEL NO:

C. MATRICULATIONS / DIPLOMA (Please attach Copy of Offer Letter & Results) UNIVERSITY MATRICULATIONS / DIPLOMA MAJORING (IF ANY) MONTH & YEAR OF COMMENCEMENT/COMPLETION CURRENT / FINAL CGPA

D. APPLICATION TO DEGREE PROGRAM (MATRICULATION/DIPLOMA/STPM STUDENTS) CHOICES 1st Choice 2nd Choice 3rd Choice UNIVERSITY DEGREE DURATION OF STUDY

E. IF CURRENTLY UNDERGOING DEGREE PROGRAM (Please attach Offer Letter & Latest Results) UNIVERSITY CURRENT SEMESTER TUITION FEES PER YEAR (RM) F. CO-CURRICULAR ACTIVITIES Past 2 Years ONLY SPORTS ACTIVITIES (Please attach Certificates) YEAR LEVEL REPRESENTED/ POSITION HELD SPORT/ CLUBS / SOCIETIES (Please attach Certificates) DEGREE NUMBER OF SEMESTERS TO COMPLETE MAJORING (IF ANY) CURRENT CGPA

MONTH & YEAR OF COMMENCEMENT/ COMPLETION

OTHER ACTIVITIES (Please attach Certificates) YEAR LEVEL OF POSITION HELD (MPP/HEAD OF RESIDENCE ETC) ACTIVITIES

G. FAMILY BACKGROUND SIBLINGS INFORMATION NAME AGE OCCUPATION / FORM / STD COMPANY / SCHOOL / INSTITUTION MOTHER (Please attach NRIC) FULL NAME AS PER NRIC NRIC NO. MOBILE NO. STATUS / OCCUPATION COMPANY ADDRESS MONTHLY INCOME

i. ii. iii. iv. v.

FATHER (Please attach NRIC)

FULL NAME AS PER NRIC NRIC NO. MOBILE NO. STATUS / OCCUPATION COMPANY ADDRESS

MONTHLY INCOME (Please attach Payslip)

MONTHLY INCOME (Please attach Payslip)

H. PLEASE STATE BELOW IF PARENT(S) IS EMPLOYEE OF PROTON NAME OF EMPLOYEE STAFF NO. DATE JOINED DESIGNATION / GRADE

UNIT / DEPARTMENT /DIVISION OFFICE CONTACT NO.

I. OTHER INFORMATION (Please attach Offer Letter of Loan/Sponsorship) ARE YOU HOLDING PTPTN LOAN? IF YES, PLEASE STATE AMOUNT (RM) PER YEAR ARE YOU HOLDING OTHER SPONSORSHIP? IF YES, PLEASE STATE AMOUNT (RM) PER YEAR NAME OF ORGANIZATION / SPONSORSHIP

J. DECLARATION

I, hereby declare that the information given in this application form is complete, accurate and I agree to abide by the above conditions. I understand that any information given falsely or withheld will affect the decision of my application, and may result in my ineligibility for the scholarship award.

Signature of Applicant Date :

The complete application form with all relevant documents should be sent by 30 April 2012 to:- THE DIRECTOR GROUP HUMAN RESOURCE (YAYASAN PROTON) PROTON HOLDINGS BERHAD HICOM Industrial Estate, Seksyen 26 40000 Shah Alam SELANGOR DARUL EHSAN
Please indicate YAYASAN PROTON Scholarship Program 2012/13 on top left-hand corner of the envelope.