Preferred Degree Details

Preferred Course 1 Preferred Course 2 Preferred Course 3 Bachelor of Bachelor of Bachelor of Accounting Banking & Finance Economics

Personal Details
Full Name (as per NRIC): Identification No.: Sex: Citizenship: House Tel No.: E-Mail Address: Permanent Address: Abu Bin Mohd Sam 940401-00-1234 Male / Female Malaysian 03-8765 4321 abu@e-mail.com Blk 12, Villa Saitama Desa Kampung Pandan 12345 Shah Alam, Selangor Same as above Date of Birth: Ethnicity: Religion: Mobile Tel No.: 01 / 04 / 1994 Malay Islam 012-345 6789

Correspondence Address: (if different from above)

Qualifications
Level Secondary School Others Name of School SMK Desa Kampung Pandan Royal School of Music Qualification SPM Piano
A

Grade Obtained
B C D Others

Year (Completed) 2011 2010

10 Grade 6

Co-Curricular Activities
Most recent activities in which you assumed leadership position(s) Year 2011 2011 2011 Position Held President Vice President Treasurer Society / Club / Activity Malay Debate Club Red Crescent Society Archery Club Institution SMK Desa Kampung Pandan SMK Desa Kampung Pandan SMK Desa Kampung Pandan

Most recent sports activities represented Year 2011 2011 2011 Sport Activity Archery 100m Race Badminton Level Represented School School State Institution SMK Desa Kampung Pandan SMK Desa Kampung Pandan SMK Desa Kampung Pandan

Most recent academic awards & commendations received Year 2011 2011 2008 Awards/Commendations Received Award for Outstanding Achievements in Education Bronze Medalist for National Badminton Tournament 2011 State Level Scholarship Award Holder for SMK Desa Kampung Pandan

Family Particulars

Please fill in the details of all your immediate family members and/or guardian(s) Full Name Mohd Sam Bin Mat Nor Salmah Binti Ahmad Kasmiah Binti Mohd Sam Syamim Bin Mohd Sam Kristina Binti Mohd Sam Relationship Father Mother Sister Brother Sister Age 57 53 25 15 8 Occupation Plumber Housewife Clerk Student Student Marital Status Married Married Married Single Single Monthly Gross Income * RM1200 RM1400 -

* Please indicate currency

Monetary Aid from Other Organisations

Please state all monetary aid previously received & currently receiving Organisation SMK Desa Kampung Pandan Amount RM800 Form of Assistance (Scholarship/Loan) Scholarship Period of Aid (yyyy yyyy) 2008-2011

Guarantors Details
All nominated guarantors must have good credit and earn a monthly income
Guarantor 1

Full Name (as per NRIC): Identification No.: Relationship: Occupation: House Tel No.: E-Mail Address: Permanent Address:

Mohd Sam Bin Mat Nor 550128-00-4321 Father Plumber 03-8765 4321 Deplumber@e-mail.com Blk 12, Villa Saitama Desa Kampung Pandan 12345 Shah Alam, Selangor Kassim Bin Ahmad 811113-00-0987 Uncle Harvester 05-312 1244 palmoil@e-mail.com Kampung Meranti, Taman Tanjung Malim 54321 Tanjung Malim, Perak Date of Birth: Citizenship: Monthly Gross Income: Mobile Tel No.: 13 / 11 / 1981 Malaysian RM2403 010-123 4321 Date of Birth: Citizenship: Monthly Gross Income: Mobile Tel No.: 28 / 01 / 1955 Malaysian RM1200 018-765 4321

Guarantor 2

Full Name (as per NRIC): Identification No.: Relationship: Occupation: House Tel No.: E-Mail Address: Permanent Address:

Declaration
Have you ever been convicted by a Court of Law of any country? Yes / No

If yes, please give brief details: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Are you or any of your family members suffering / have suffered from any medical conditions (mental and physical) which requires regular or prolonged medical treatment? Yes / No If yes, please give full details: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Please list if you have relatives working in Maybank Group: Name of Relative Azita Binti Muhammad Hakim Relationship Cousin Personnel No. 00012345 Branch / Department Telok Gong Branch

I hereby declare that the information provided in this application form is true and correct and I authorise and consent to Maybank obtaining official records, if necessary, from any educational institution attended by me. I understand that any provision of inaccurate or false information or omission of information will render this application invalid and that, if admitted on the basis of such information, I can be required to withdraw from the scholarship.

____________________________ Signature of Applicant Date: _______________________

Checklist of Document Submitted

Recent Passport-size photo Identification Card (front & back) for: Applicant Both parents and/or guardian(s) Both guarantors Examination results Testimonial and recommendation letter from school Leaving school certificate Co-curricular certificate(s), etc. Latest Income Tax Return, EA Form, Payslip/Proof of Income AND EPF Statement for: Both parents and/or guardian(s) Both guarantors Siblings