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CONFIDENTIAL Rev. 1/2010

SHELL MALAYSIA

2010 SCHOLARSHIP APPLICATION FORMCLOSING DATE: 31 March 2010

Please affix yourrecent passport-sized

photograph.

IMPORTANT INFORMATION

1. The scholarship is awarded to Malaysian students pursuing full-time undergraduatestudies (1st degree course) tenable at recognized universities in Malaysia or overseas, and Pre-University studies in Malaysia.2. Students who have completed their SPM/O-Level, STPM/A-Level/Foundation Year/Diploma orcurrently in their final semester of Matriculation studies or currently in Year 1 in the University(IPTA/IPTS) are eligible to apply.

3. Please complete the form in BLOCK LETTERS.4. If the space is insufficient, please give further information on a separate sheet of paper.5. INCOMPLETE and LATE application will be rejected.

6. If you do not receive any reply from us by 30 April 2010, your application is thereforeconsidered unsuccessful.

7. *Please delete whichever is NOT applicable.

8. Note: The Scholarship Application Form should be submitted ONLINE via the Shell MalaysiaOnline Application website onWWW.SHELL.COM.MY - Jobs & Careers - Students & Graduates Scholarship.9. For further enquiries, please email to scholarships@shell.com

APPLICATION TYPE []: (The Company reserves the right to change the Application Type.)

Malaysia Overseas

1. PERSONAL PARTICULARSNAME (as per your MyKad)

DEVARAJ A/L SHANMUGAM__________________________________________________________

GENDER : Male ETHNIC : Non-Bumi* NRIC NO.______________________________________:901214-13-6789

AGE : 20___years old RACE : INDIAN_________________ DATE OF BIRTH :14-12-1990

RELIGION:_________________________HINDUSTATE OF ORIGIN: Sarawak HOMETOWN:KUCHING_______________________

PREFERRED PLACE OF INTERVIEW : KUCHING

(Your selected location should be nearest to your current hometown. All travel expenses incurred will be on the applicantspersonal account. The Company reserves the right to change the location of interview.)

CORRESPONDENCE ADDRESS : (Please ensure that your address, email andcontact nos. are active.)

_________________________________________________________________________________ Tel. No. : 082-572644__________________

_________________________________________________________________________________ HP No. : 016-8550837________________

_________________________________________________________________________________ E-Mail : raj_deva90@yahoo.com______

_________________________________________________________________________________ Post Code :93250___________________________________________________________________________

Any physical disability (eg. sight, hearing, speech):NO

Any previous illness/operation :NO

2. FAMILY PARTICULARS

Particulars Father Mother Name SHANMUGAM A/L SHANMUGAM KANIYAMA A/P KRISHNASAMY

Occupation

Basic Salary/Income(RM)

Employer

Race

Ethnic Bumiputra/Non-Bumiputra* Bumiputra/Non-Bumiputra*

State of Origin Sarawak/Sabah/Others* Sarawak/Sabah/Others*

Note: Please produce a supporting document if your parent do not have a payslip (applicable to retiree,pensioner, fisherman, farmer, unemployed, amah/baby-sitter), handicap, separated, divorced or deceased.

FOR OFFICIAL USEEducation Level Status Remarks

SPM/O-Level/ STPM/A-Level

Result/Grade : ..................

REJECTED [NotMeeting Criteria/

Type :Malaysia/Overseas

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Diploma/Matrix/Foundation/Undergraduates

GPA/CGPA : .....................

LEVEL/SEMESTER...................:

Incomplete/Origin]

CONSIDERED [Meetingminimum criteria]

SHORTLISTED[Invitation forInterview]

Parents Income :RM3K

...................................................

...................................................

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Do you have any brother or sister currently holding the Shell Scholarship? YES/NO* If yes, please complete thefollowing:

Name Relationship Institution

Relatives working in ShellName Relationship Dept. & Office Contact No.

3. EDUCATION QUALIFICATION

Please [] your highest qualification.

SPM/O-LEVEL* YEAR : 200_____

STPM/A-LEVEL* YEAR : 200_____

DIPLOMA/MATRIX/FOUNDATIONYEAR/UNDERGRADUATES*

OTHERS: ..............................(please specifiy)

LEVEL:YEAR : [1]/[2]/[3]*

SEMESTER : [1]/[2]/[FINAL]*

School (for SPM) : ......................................................................................

School (for STPM) : ......................................................................................

College/University : ......................................................................................

Course : ......................................................................................

Intake Year : 200........

Course Duration : [3]/[4]/[5]/OTHERS*......................YEARS (please specify)

Expected Completion (Mth/Yr)..............................:............. /20

Please state your choice of courses that you intend to apply. If you are already in the university, please ignore this section.

CHOICE COURSE1st

2nd

4. EXTRA CURRICULAR ACTIVITIES (2008-2009)

Please use separate sheet if space is insufficient.CLUBS/SOCIETIES/OTHERS

YEAR ACTIVITIESREPRESENTED POSITION HELD

(Please refer to the list below)EG. 2008 -2009

2009 -2010

Interact ClubSwimming

-National

President-

REPRESENTED : House; School; District; Division; State; NationalPOSITION HELD : Chairman; President; Vice/Dep. President/Chairman; Captain/Leader; Treasurer; School Prefect;Secretary; Assistant; etc.

5. SPECIAL AWARDS RECEIVEDYEAR TYPE OF AWARDS GRANTED/SPONSORED BY

6. OTHER INFORMATIONAre you currently receiving any financial assistance or sponsorship from other institution, fund or foundation? YES/NO* If YES,please give details:

Institution/Fund/Organisation/Foundation (eg. JPA, MARA, PETRONAS, PTPTN, etc.) Year Amount (RM)1)

2)

7. DECLARATION

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I declare that all the above particulars are true and correct. I understand that, should I accept a scholarship and any of theabove information is found to be false, the scholarship will be held liable to repayment of monies expended. I also understandthat the completion of this form does not commit the Shell Scholarship Fund to assisting me in any way.

I enclosed herewith my certified copy of the supporting documents [ ].

(1) Birth Certificate & Identity Card

(2) Results SPM/O-Level/STPM/A-Level/Matrix/Foundation/Diploma/Year 1

(3) School Testimonial (Surat Akuan), Certificates of Achievements, School Co-Curricular Activities, etc.

(4) 2 latest semester results (applicable to those currently in the Matriculation/Foundation Year/Diploma/University)

(5) Letter of Offer from the University (applicable to those currently in the University)

(6) Parents' Identity Card, 2-month Latest Salary Slip/Income Tax Statement (Form J) or any other supporting document ofmy parents status.

Applicant's Signature:_________________________________ Date____________________________:

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