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

IC / Pasport Number: Nationality: Date of Birth: Age:

Sex: (M/F) Marital Status: Race: Religion:

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 :

Name of Programme:

Centre of Study:

Intake (Month / Year): Duration (semesters):

(Please submit certified copies of relevant certificates)

a) Schools / Colleges / Universities attended and qualification achieved

Year

PMR

SPM / SPVM / O Level

STPM / A Level / Matriculation

Others (Please specify) :

b) Scholarship / Study Loan Or Sponsorship received

YearType of Scholarship / Loan Agency Duration

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

Section 1: PERSONAL DETAILS

please affix a pasport-sized photo

Section 2: PROGRAMME OF STUDY

Section 3: ACADEMIC QUALIFICATIONS

Qualification Completed Schools / Institutions City / State

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

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

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)

Section 4: CO CURRICULAR & OTHER ACTIVITIES

Section 5: FAMILY BACKGROUND

Details Father Mother

No. Age

1

2

3

4

5

6

7

8

9

10

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

incomplete information.

Applicant's signature

Date: _______________________________

The application is:

Type of scholarship awarded:

Remark:

Section 6: SIBLINGS

Name Occupation / School

successfull unsuccessfull

DECLARATION BY APPLICANT

FOR OFFICE USE ONLY

NOTES AND INSTRUCTIONSThis 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) oror 'Resit Penukaran Kad Pengenalan' (JPN 1/22) issued under the National Registration Act (1959) where applicable.

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

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

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

6 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.

7 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.

8 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)