FOR POSTGRADUATES

Guide :
1. Use UPPERCASE to complete this form.
2. Attach certified true copies of academic transcript/results and other documents.
3. Ensure all information given are correct.
4. Completed forms to be sent to : Yayasan Khazanah, P. O. Box 13080, 50798 Kuala Lumpur, OR
c/o UEM Education Development & Support, 19th Floor, Menara 1, Faber Towers, Jalan Desa Bahagia, Taman Desa,
58100 Kuala Lumpur.

A. DEGREE TO PURSUE Master PhD

UNIVERSITY PLACEMENT Yes No

ALREADY SECURED :

If Yes, name of University 1.       Choice of Discipline:

(Rank according to      
preference)

2.       Choice of Discipline:

     

3.       Choice of Discipline:

     
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B. PERSONAL PARTICULARS
1. Full Name      

2. I.C. No. (New)       3. Place of Birth      

4. Age    5. Gender FEMALE MALE

6. Race       7. Marital Status      

8. Religion      

9. Permanent Home      

Address      
     
Postcode       State      
10. Tel. No. (House)       11. Tel. No.(H/P)      

12. E-mail Address      

C. ACADEMIC PERFORMANCE

I. MASTERS

Institution / University :      

State :       Country :      

Discipline :       CGPA/Grade      

Year From :       To :      

II. PROFESSIONAL QUALIFICATIONS ATTAINED

Professional Body :      

State :       Country :      

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 Name Of Professional :      

Year From :       To :      

Part Completed All Part

     
III. UNDERGRADUATE / FIRST DEGREE

Institution / University :      

State :       Country :      

Discipline :      

Year From :       To :      

CGPA/Grade :       Points/Class :      

IV. DIPLOMA

Institution / University :      

State :       Country :      

Discipline :       CGPA/Grade      

Year From :       To :      

D. EXTRA CURICULLAR ACTIVITIES (Last two years ONLY)

POSITION/ROLE AWARDS/
NO. SOCIETIES/CLUBS YEAR
ASSUMED COMMENDATIONS RECEIVED

POSITION/ROLE AWARDS/
NO. SPORTS/GAMES YEAR
ASSUMED COMMENDATIONS RECEIVED

POSITION/ROLE AWARDS/
NO. OTHERS YEAR
ASSUMED COMMENDATIONS RECEIVED

E. EMPLOYMENT (if relevant)

PLEASE PROVIDE DETAILS OF CURRENT / PREVIOUS EMPLOYMENT, IF ANY :
1. Employer Name and
Address
2. No. of year with
current employer
3. Current position in
the company
4. Current monthly
salary

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 5. Professional award
and honours

F. REFEREES

PLEASE NAME TWO REFEREES TO WHOM WE COULD CONTACT FOR A PERSONAL REFERENCE ABOUT YOUR
ACADEMIC AND / OR PROFESIONAL ACHIEVEMENTS.

REFEREE 1

1. Name

2. Address

3. Position

4. Email

REFEREE 2

1. Name

2. Address

3. Position

4. Email

G. DECLARATION

I HEREBY DECLARE THAT THE PARTICULARS PROVIDED IN THIS FORM ARE TRUE IN EVERY RESPECT.
I UNDERSTAND THAT IF ANY OF THESE PARTICULARS GIVEN BY ME ARE FOUND TO BE UNTRUE,
MY APPLICATION WILL BE DISQUALIFIED.

SIGN DATE

YAYASAN KHAZANAH © All rights reserved 3