PANASONIC SCHOLARSHIP APPLICATION FORM

A. PERSONAL PARTICULARS
Full Name (as per NRIC) :
Identification No :

Date of Birth :

Gender :

Nationality :

Male / Female

Phone No :

Emergency Contact :

Mobile No :

Name / Relationship :

(dd/mm/yy)
Latest color
passport size photo

Email :
Permanent Address

Correspondence Address

B. GUARDIAN'S PARTICULARS
1st Person

2nd Person

Full Name :

Full Name :

Relationship :

Relationship :

Identification No :

Identification No :

Phone No /Mobile No :

Phone No /Mobile No :

Occupation :

Occupation :

Company Name (if applicable):

Company Name (if applicable):

Office Tel No :

Office Tel No :

Monthly Income (Please attach payslip) :

Monthly Income (Please attach payslip) :

C. SIBLINGS INFORMATION
Name

Age

Relationship

Occupation/School

D. CURRENT DEGREE PROGRAM

Majoring :
University :
Current GPA :
(Please attach CERTIFIED TRUE COPY of result up to the present)

E. CO-CURRICULAR ACTIVITIES
Sport / Club / Society

Year

Position Held

Experience Gained

i
ii
iii
iv

F. FINANCIAL SUPPORT (S)

Are your parents financing your studies ?

Yes / No

If no, please state the name of the institution / foundation :

if yes, please state the amount (RM) per year :

G. Reference
Name (Advisor) :

Email / Contact No :

H. DECLARATION
1 I hereby declare that the information provided in this form is true and correct. I understand that any information given falsely or witheld will
affect the decision of my application, and may result in my ineligibility for the scholarship award.
2 I understand that personal data provided in this form will be used for verification & scholarship application purpose only
3 All decisions made by Panasonic on matters pertaining to the scholarship will be final

.
Signature of Applicant
Name :
NRIC :
Date :

Documentation Checklist
Completed application form
Certified true copy academic result by University Assistant Registrar
- Intake 2012 - 3 semesters CGPA
- Intake 2013 - 1 semester GPA
Photocpy of Identity Card
Recent passport size color photo x 1pc