Preliminary Application Form 2017 Recent Photo

Borang Permohonan 2017

Gambar Terbaru 

All forms must be HANDWRITTEN clearly in BLACK or BLUE ink pen and every question must be answered.
Setiap borang hendaklah ditulis dengan jelas menggunakan dakwat HITAM atau BIRU sahaja. Sila jawab semua soalan dengan lengkap.

CHECKLIST‐ SENARAI SEMAK  
Check that you have filled ALL the information on this form and include:
Semak semula SETIAP maklumat yang telah diisi dan sertakan lampiran yang berikut:

Your past 2 years’ school results (Compulsory)

Keputusan peperiksaan terkini bagi 2 tahun lalu (Wajib)

A photocopy of your IC (both side) (Compulsory)

Satu salinan kad pengenalan (kedua-dua belah) (Wajib)

A recent passport photograph of yourself (Compulsory)

Gambar ukuran passport yang terbaru (Wajib)

PERSONAL INFORMATION – MAKLUMAT PERIBADI  
Full name (as in IC) – Nama Penuh (seperti dalam K/P) Birth date – Tarikh Lahir Gender- Jantina
(dd/mm/yy)
Male
(Lelaki)
Home Phone Number – No. Telefon Rumah: Mobile Number – No. Telefon Bimbit:
Female
(Perempuan)

Home Address - Alamat Rumah: Do you have a disability?

Adakah anda mengalami sebarang kecacatan fizikal?

Yes/Ya
No/Tidak

Email Address - Alamat Emel: If Yes, please give details: (Jika Ya, sila nyatakan:)

Kennedy Lugar YES program Overview: Eligibility for Disabled participants

The Kennedy Lugar Youth Exchange and Study (YES) Program was established
by Congress, 2002 in response to the events of September 11, 2001. The program
is funded through the U.S State Department of State and sponsored by the Bureau
of Educational & Cultural Affairs (ECA) to provide scholarships for high school
students (15-17 years) from countries with significant Muslim populations to spend
up to one academic year in the U.S. In Malaysia, the YES Program is implemented
by AFS.
In keeping with the U.S. Government-sponsored initiatives, dedicated to democratic
reform, the competition for the Youth Exchange and Study scholarship is merit-
based and open at no cost to all applicants who meet the following requirements:
Eligibility for General participants
1. Be 15-17 by the start of program (if selected, you leave in January of
2017) and sitting for SPM or its equivalent this year;
2. Be enrolled in Form 5 at the time of application;
3. Have the equivalent of a B average or better without failing grades;
4. Be a citizen of Malaysia.
The program can support students with disabilities and encourages their
participation. The Department of State and the YES program work with
Mobility International (MIUSA) to provide students with disabilities
leadership-building workshops, appropriate information and support as needed
to enhance their year in America. Students with disabilities must meet the
following eligibility requirements:
 Be 15-17 by the start of program (if selected, you leave in
January of 2017) and sitting for SPM or its equivalent this year;
 Be enrolled in Form 3-5 at the time of application;
 Have the equivalent of a B average or better without failing grades;
 Be a citizen of Malaysia.
Note:
Priority will be given to underprivileged applicants with little or no previous
experience in United States.
Please submit only photocopy of original documents.
AFS Malaysia will not be responsible in sending back original copies

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PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA
SCHOOL INFORMATION‐ MAKLUMAT SEKOLAH  
Name of School- Nama Sekolah:

School Address- Alamat Sekolah:

Telephone Number- No. Telefon: Fax Number- No. Fax:

I am in Form (kindly provide class name): Type of School (Please tick)

Saya di tingkatan (sila nyatakan nama kelas): Jenis Sekolah (Sila tandakan)

Residential / Asrama Penuh

Religious / Sekolah Agama
Private School / Sekolah Swasta
Post held in school (if any):
Jawatan disandang di sekolah (jika ada): Special Education / Pendidikan Khas
Daily School / Sekolah Harian:
o Sekolah Menengah Kebangsaan
o Sekolah Jenis Kebangsaan Cina
o Sekolah Jenis Kebangsaan India
o Lain-lain: __________________

PARENTS/GURDIAN(S) INFORMATION‐ MAKLUMAT IBU BAPA/ PENJAGA 

What is your family structure? / Apakah status ibu bapa anda?

Parents are: / Ibu bapa saya:
married separated single parent divorced
berkahwin tinggal berasingan ibu/bapa tunggal berpisah

Information about the people with whom I live / Maklumat ibu/bapa yang saya tinggal bersama:

I live with: both my father and my mother my mother my father stepmother stepfather
Saya tinggal bersama: Kedua ibu bapa saya ibu sahaja bapa sahaja ibu tiri bapa tiri

my guardian(s), indicate your relationship to your guardian(s), ______________

penjaga, hubungan saya dengan penjaga ialah _______________

Father/Guardian: Divorced Deceased Separated

Bapa/Penjaga: Bercerai Meninggal Berpisah
Father/Stepfather/Guardian Name- Nama Bapa/Bapa Tiri/Penjaga:

Employer- Majikan: Occupation-Pekerjaan:

Office Number- No. Pejabat: Mobile Number-No. Telefon Bimbit: Email Address- Alamat Emel:

Mother/Guardian: Divorced Deceased Separated

Ibu/Penjaga: Bercerai Meninggal Berpisah
Mother/Stepmother/Guardian Name- Nama Ibu/Ibu Tiri/Penjaga:

Employer- Majikan: Occupation-Pekerjaan:

Office Number- No. Pejabat: Mobile Number-No. Telefon Bimbit: Email Address- Alamat Emel:

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PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA
 SIBLING(S) INFORMATION‐ MAKLUMAT ADIK‐BERADIK 

Name-Nama Age-Umur Gender-Jantina School/Institution-Sekolah/Institusi

EMERGENCY CONTACT‐MAKLUMAT KECEMASAN  

If your parents/guardian cannot be reached, please indicate someone in your community whom we can contact:
Jika ibu bapa/penjaga tidak dapat dihubungi,sila nyatakan maklumat individu yang boleh dihubungi:

Full Name-Nama Penuh: Relationship-Hubungan:

Office Phone-No.Telefon Pejabat: Home Phone- No.Telephone Rumah: Mobile Number- No. Telefon Bimbit:

LANGUAGE BACKGROUND 
What are the primary languages spoken in your home? / Apakah bahasa pertuturan anda di rumah?

Malay / Bahasa Melayu English / Bahasa Inggeris

Mandarin / Bahasa Mandarin Others / Lain-lain: _______________

Tamil / Bahasa Tamil

What other languages do you know? Please indicate your speaking ability in each language. / Apakah bahasa pertuturan lain yang anda tahu?
Sila nyatakan kemahiran bertutur anda.

Language/ Year of studies/ Speaking abilities/ Study at/

Bahasa: Tahun Pengajian: Kemahiran Bertutur: Belajar di:
    Poor  Fair  Good  Excellent  School  Extra Course 
Lemah  Sederhana  Baik  Sangat Baik  Sekolah  Kelas Tambahan 
    Poor  Fair  Good  Excellent  School  Extra Course 
Lemah  Sederhana Baik Sangat Baik Sekolah  Kelas Tambahan
    Poor  Fair  Good  Excellent  School  Extra Course 
Lemah  Sederhana  Baik  Sangat Baik  Sekolah  Kelas Tambahan 
    Poor  Fair  Good  Excellent  School  Extra Course 
Lemah  Sederhana  Baik  Sangat Baik  Sekolah  Kelas Tambahan 

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PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA
 PERSONAL STATEMENT – PENGENALAN DIRI  

1. Tell us about yourself: Introduce yourself, your personality, your relationship with your family and friends, your responsibilities at
home/school, list your favourites, interests or hobbies etc./ Perkenalkan diri anda, personaliti anda, hubungan anda dengan keluarga dan
rakan-rakan, tanggungjawab di rumah / sekolah, senaraikan kegemaran, minat atau hobi anda.
2. Tell us about your expectation (before,during & after) the exchange program / Sila nyatakan harapan anda (sebelum, semasa & selepas)
program pertukaran ini.
3. Tell us about your participation in school and community activities / Senaraikan penyertaan anda di sekolah dan aktiviti-aktiviti
kemasyarakatan
4. Tell us about your goals/plans which are important to you; and why you think you should be chosen for the YES Program? / Sila nyatakan
matlamat / perancangan yang penting kepada anda; dan mengapa anda layak dipilih untuk Program YES?

** Your personal statement should be between 100 -250 words ONLY / Kenyataan diri anda haruslah di antara 100-250 patah perkataan
SAHAJA

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PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA
 OTHER INFORMATION ‐ MAKLUMAT LAIN  

How did you hear about AFS? - Bagaimanakah anda tahu mengenai AFS?

Online/Atas Talian School/Sekolah Road Show/ Promosi Bergerak

Friends / Rakan Newspaper / Surat Khabar Others / Lain-Lain

__________________

Have any of your family members participated on an AFS program? Adakah sesiapa dari ahli keluarga anda yang pernah menyertai
program AFS?

No/Tidak Yes, please specify student’s name, host country and which year? Ya.Sila nyatakan nama
Pelajar, negara dan tahun penyertaan.

Are you or any of your family members involved in AFS? Adakah anda atau sesiapa dari ahli keluarga anda terlibat di dalam AFS?
No/ Tidak Yes. If yes,how?/ Ya.Jika ya, bagaimana?

Do you have any volunteer experience? If yes, please list your volunteer activities.
Sila nyatakan disini sekiranya anda mempunyai sebarang pengalaman dalam aktiviti sukarelawan.

1. ______________________________________________________________ Year/Tahun: _________________

2. ______________________________________________________________ Year/Tahun: _________________

3. ______________________________________________________________ Year/Tahun: _________________

4. ______________________________________________________________ Year/Tahun: _________________

5. ______________________________________________________________ Year/Tahun: _________________

Are you willing to host an AFS participant?

Adakah anda sudi menjadi keluarga angkat kepada peserta AFS?

Yes / Ya
No / Tidak

Have you ever participated in any other exchange programs, travelled abroad or lived in another country?
(Please provide details; exchange program name, travel duration and country name)
E.g.: UCC Summer Course in England in 2014 for two weeks (15 -29 November, 2014)

Adakah anda pernah menyertai mana-mana program pertukaran, melancong atau menetap di luar negara?
(Sila nyatakan nama program, tempoh dan nama negara)
Cth: UCC Summer Course di England pada tahun 2014 selama 2 minggu (15 -29 November, 2014)

No/ Tidak Yes. If yes, where and when, for what purpose? / Ya. Jika ya, dimana dan bila? Tujuan?

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PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA
 INTERESTS AND ACTIVITIES 
Please (√) select 5 to 10 activities of your interests below.
Sila (√) pilih 5 hingga 10 aktiviti kesukaan anda di bawah.

Individual Sports:

Hiking Horseback Riding Cycling Sailing/Boating Camping Canoeing Fishing

Mendaki Menunggang Kuda Berbasikal Berlayar Berkhemah Berkayak Memancing

Yoga Skateboarding Aerobics Hunting Jogging Martial Arts

Yoga Bermain Papan Luncur Aerobik Memburu Joging Seni Mempertahankan Diri

Organized Sports:

Hockey Baseball Basketball Gymnastic Softball Wrestling Tennis

Hoki Baseball Bola jaring Gimnastik Softball Gusti Tenis

Soccer Track & Field Diving/Swimming Volleyball Golf Cross-country Running

Bola Sepak Aktiviti Padang Menyelam/Berenang Bola Tampar Golf Merentas Desa

Art, Dance and Theatre:

Ballet Drawing/painting Debate Photography Videography

Balet Melukis Debat Fotografi Videografi
Theatre/Drama Movie/Cinema Cultural Activities Crafts Dance
Teater/Drama Menonton wayang Aktiviti Kebudayaan Kraf Tarian

Music:

Musical Instrument Singing Orchestra Concert Listening to Music Brass Band

Alat Musik Menyanyi Orkestra Konsert Mendengar Musik Pancaragam

Individual:

Board Games Social Dancing Collecting Gardening Journalism Travel

Mainan Tarian Social Mengumpul Berkebun Penulisan Melancong

Cooking Reading Watching Television Computer Games

Memasak Membaca Menonton Television Permainan Komputer

Community Activities:

Religion Services School Activities Scouts/Guides Volunteer Activity

Khidmat Keagamaan Aktiviti Sekolah Pengakap Aktiviti Sukarela

DECLARATION‐ AKU JANJI  

I have discussed my application with my family and wish to apply for participation in the Kennedy Lugar Youth Exchange and Study
(YES) program

Saya telah berbincang dengan keluarga saya mengenai permohonan ini dan ingin memohon untuk menyertai program Kennedy
Lugar Youth Exchange and Study (YES)

Applicant’s Signature / Tandatangan Pemohon Parent/Guardian’s Signature / Tandatangan Ibu/Bapa/Penjaga

Date/Tarikh: Date/Tarikh:

Page 6 of 7
PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA
YES PROGRAM APPLICATION- PERMOHONAN PROGRAM YES

Please note that, applications to the YES program does not automatically guarantee you a spot for the YES Program. Your application
will be reviewed by the AFS Selection Committee to determine your eligibility participate in the program.
We trust that your information in this application is valid, failing which your application will be disqualified.

Adalah dimaklumkan bahawa permohonan ini tidak secara automatik melayakkan anda untuk sebarang biasiswa AFS. Permohonan anda
akan ditapis oleh Jawatankuasa Pemilihan AFS bagi menentukan samada anda layak untuk mengikuti Program ini.
Sekiranya didapati sebarang maklumat yang diberi tidak benar, permohonan anda akan terbatal.

Family Annual Income (Please tick):

Pendapatan tahunan keluarga (Sila tandakan):

Up to RM30,000 / Sehingga RM30,000 RM31,000-RM50,000 RM51,000-RM70,000

RM71,000-RM99,000 RM100,000 and above/

Lebih dari RM100,000

Number of dependents /Jumlah tanggungan: ________________________________________________________________________

SUBMISSION POLICY /POLISI PENGHANTARAN

Send this completed application form on or before 30 April 2017 to:
Hantarkan borang permohonan yang lengkap sebelum atau pada 30 April 2017 kepada:

SENDING DEPARTMENT
  AFS MALAYSIA
  A-10-2, Block A, Plaza Glomac,
Jalan SS 7/19, Kelana Jaya
  47301 Petaling Jaya,
Selangor Darul Ehsan
Malaysia

APPLICATION DEADLINE/ TARIKH TUTUP:

30 APRIL 2017

IMPORTANT NOTES:

1. All applications must be submitted to AFS Malaysia office as printed copies, applications submitted via online (via email)
will not be considered.
Semua salinan permohonan perlu dihantar ke pejabat AFS Malaysia, penghantaran melalui atas talian (melalui emel) tidak akan
dilayan.

2. Applicants must submit only photocopy of original documents (IC, school results, and certificates). AFS Malaysia will
not be responsible in sending back original copies.
Permohonan mestilah dihantar dengan salinan dokumen asal sahaja (K/P, Keputusan peperiksaan terkini, dan sijil-sijil). AFS
Malaysia tidak akan bertanggungjawab dalam memulangkan dokumen asal anda.

3. Incomplete applications will be rejected.

Permohonan yang tidak lengkap tidak akan diproses.

4. Short listed candidates ONLY will be called for an interview in May/June 2017 (interview may be held during school
holidays). Request to change date and venue will not be entertained.
Pelajar yang disenarai pendek SAHAJA akan dipanggil untuk menghadiri temuduga pada bulan Mei/Jun 2017 (temuduga
berkemungkinan diadakan semasa cuti sekolah). Permohonan untuk menukar tarikh atau tempat temuduga tidak akan dilayan.

5. For any inquiries regarding YES Program application, please email to info-mas@afs.org with the Subject Heading: YES
Application 2017-18 Inquiry or call us at 03 7887 6866. Please note that our office hour is Monday – Friday (9am-5pm).
Bagi sebarang pertanyaan berkenaan permohonan Program YES, sila emel kepada: info-mas@afs.org dengan Tajuk Subjek:
Pertanyaan Permohonan YES 2017 – 18 atau hubungi kami di talian 03 7887 6866. Pejabat kami beroperasi pada hari Isnin
hingga Jumaat (9 Pagi- 5 Petang).

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PRELIMINARY APPLICATION / YAYASAN AFS ANTARABUDAYA MALAYSIA