This document is a scholarship application form for the Yayasan Bursa Malaysia Scholarship Programme. It requests personal details of the applicant such as name, date of birth, citizenship, address, academic qualifications, extracurricular activities, details of any previous scholarships, intended course of study, and financial details of parents/guardians. The applicant must declare that all information provided is accurate and the form includes verification sections to be completed by an employer, headmaster, or government official to validate the applicant's information. Required supporting documents are also listed.

1. A. Personal Particulars
Name:
Date of birth: Place of birth: Age:
Citizenship: I/C No:
Permanent address:
E-mail Address:
House telephone no: Hand phone no:
Are any of your parents an employee of Bursa Malaysia?
Yes. Name: ___________________________________________
No
How do you come to know about the Yayasan Bursa Malaysia Scholarship?
Newspaper
Bursa Malaysia website
Word-of-mouth/ Friends/Relatives
Others (please specify): __________________________________
Yayasan Bursa Malaysia Scholarship Programme
Scholarship Application Form 2015/2016
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YAYASAN BURSA MALAYSIA SCHOLARSHIP PROGRAMME
Scholarship Application Form 2015/2016

2. B. Academic Details – Please tick ()
STPM A-LEVELS MATRICULATION FOUNDATION
SCHOOL/INSTITUTION:
YEAR TAKEN:
SUBJECT GRADE SUBJECT GRADE
Malaysian University English Test (MUET): Band _______
Cumulative Grade Point Average (CGPA):
Sem. 1 Sem. 2 Sem. 3 Sem. 4
SPM Year:
SUBJECT GRADE SUBJECT GRADE
GCE ‘O’ Level English (1119): Grade _______
Yayasan Bursa Malaysia Scholarship Programme
Scholarship Application Form 2015/2016
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3. C. Extra-Curricular Activities - Please tick ()
Represented
Sports School University
/college
District State Country
Role
Uniform troop / Association
/ Club
Member Treasurer Secretary Vice
President
President Ad-hoc
Committee
D. Scholarship History- Please tick ()
Have you received any scholarship before? Yes No
If yes, please provide details:
Sponsor Organization Duration
Value
(RM/Year)
Are you currently bonded to any scholarship agreement? Yes No
E. Course/Programme Details Applied for this Scholarship
Programme of study
(eg: Bachelor In Accountancy)
Name of institution
(eg: Universiti Malaya)
Commencement date/ session
(eg: 1/8/12 / Semester I, 2012/2013)
Duration of study
(eg: 4 years)
Expected graduation date:
(eg: August 2016)
Yayasan Bursa Malaysia Scholarship Programme
Scholarship Application Form 2015/2016
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4. F. Details of Father / Guardian
Name:
Citizenship: New I/C no:
Old I/C no:
Date of birth: Place of birth:
House tel no: Hand phone no:
Occupation: Monthly income:
Name & address of employer: Signature:
G. Details of Mother / Guardian
Name:
Citizenship: New I/C no:
Old I/C no:
Date of birth: Place of birth:
House tel no: Hand phone no:
Occupation: Monthly income:
Name & address of employer: Signature:
H. Details of Siblings
No. Name Age Date of
birth
Occupation/
Student
Employer/School
1
2
3
4
5
6
7
8
Yayasan Bursa Malaysia Scholarship Programme
Scholarship Application Form 2015/2016
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5. Declaration
I hereby declare that all information furnished above are accurate and true to the best of my
belief and Yayasan Bursa Malaysia reserves its rights to terminate/withdraw this application
should any information furnished be discovered as inaccurate and untrue.
Name: Applicant’s Signature:
Date:
* To be Completed By Employer of Parent/ Guardian/ Headmaster/
Principal/ Penghulu/ Government Officer within the home vicinity
I hereby verify that all information furnished above are accurate and true to my knowledge.
Name:
Designation: Signature:
Date:
Official stamp:
Note (*): If any of the parents is an employee of Bursa Malaysia Bhd, this section must be
completed by Head of Department/Section.
FOR OFFICE USE
Date received: Signature:
Note: Please check the availability and verification of the
following documents and attached them with your submission.
Please tick ( )
1. Copy of I/Cs of applicant and parents/guardian
2. Copy of examination results
3. Copy of co-curricular activities certificates/ testimonials
4.
Copy of Offer Letter from institution of higher learning (if
available)
5. Latest copy of parents/guardian salary slip
Yayasan Bursa Malaysia Scholarship Programme
Scholarship Application Form 2015/2016
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6. Declaration
I hereby declare that all information furnished above are accurate and true to the best of my
belief and Yayasan Bursa Malaysia reserves its rights to terminate/withdraw this application
should any information furnished be discovered as inaccurate and untrue.
Name: Applicant’s Signature:
Date:
* To be Completed By Employer of Parent/ Guardian/ Headmaster/
Principal/ Penghulu/ Government Officer within the home vicinity
I hereby verify that all information furnished above are accurate and true to my knowledge.
Name:
Designation: Signature:
Date:
Official stamp:
Note (*): If any of the parents is an employee of Bursa Malaysia Bhd, this section must be
completed by Head of Department/Section.
FOR OFFICE USE
Date received: Signature:
Note: Please check the availability and verification of the
following documents and attached them with your submission.
Please tick ( )
1. Copy of I/Cs of applicant and parents/guardian
2. Copy of examination results
3. Copy of co-curricular activities certificates/ testimonials
4.
Copy of Offer Letter from institution of higher learning (if
available)
5. Latest copy of parents/guardian salary slip
Yayasan Bursa Malaysia Scholarship Programme
Scholarship Application Form 2015/2016
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