Ecm Libra Foundation: Application Form Scholarship Program

ECM LIBRA FOUNDATION (671187-W)
Application Form Scholarship Program
This application form is divided into two (2) sections. Part I must be completed by the Applicant. Part II is to be completed by an academic referee who has personal knowledge of the Applicant's academic history. Applicants are to ensure that certified true copies of supporting documents are attached (see Checklist). The completed Application Form should be returned to: ECM Libra Foundation, 8A, Wisma Genting, Jalan Sultan Ismail, 50250 Kuala Lumpur. Only Application Forms accompanied by complete documentation will be considered. Only shortlisted Applicants will be notified. The Application Form must be completed LEGIBLY in BLOCK LETTERS using black ink only . All details must be provided. If the space provided is insufficient, please use separate sheet(s) of paper and number them appropriately.
PART I Personal Particulars

Name:
(Please underline surname)
New NRIC No: Date of Birth: Gender: Marital Status: Race: Home Address:
Male Single Malay Female
Old NRIC No:
Married
Chinese
Divorced
Widowed Others
Please specify
Indian
Correspondence Address:
House Tel No: Office Tel No:
Mobile No: E-mail Address:
SP/Page 1 of 6
Course of Study
Type of Scholarship applied for:
Undergraduate
Postgraduate
Others
(Please specify)
College/Institution/University gained admission/applied to (Please attach Letter of Admission/Offer) : Name: Address:
Course applied/pursuing: Duration of Course: Course Fees per annum: Date of Commencement of Course: Date of Completion of Course: RM
Academic Qualifications
(Please provide certified copies of results/certificates) Examination/Qualification Attained
No 1 2 3 4 5
Name of School/Institution
Year
Grade/Score
Extra-Curriculum Activities
(Please provide certified copies of certificates of achievements) Name of Uniformed Society or Activities participated Name of School or Event
No 1 2 3 4 5 6 7 8 9 10
Achievement Attained
SP/Page 2 of 6
Family Particulars
Father's Name: Address: Age: Tel (Hse): HP No: Occupation: Employer: Mother's Name Occupation: Employer: Age: Annual Income: HP No: Annual Income:
Particulars of Siblings
No 1 2 3 4 5 6 7 8 9 10 Name Gender Age Occupation Name of Employer/School
Particulars of Spouse (if Applicant is married)

Name:
(Please underline surname)
New NRIC No: Date of Birth: Gender: Race:

Male Malay
Female Chinese Indian
Old NRIC No: HP No:
Others
Please specify
SP/Page 3 of 6
In 200 words or less, state why you deserve to be offered this scholarship.
(continue on a separate sheet, if required)
SP/Page 4 of 6
PART II To be completed by Academic Referee

Name: Institution/Employer: Email: Address: Occupation: Tel:
1. How long have you known the Applicant?
years
months
2. How would you rate the Applicant's academic record and ability? (Please check one)
Outstanding
Excellent
Very Good
Good
Average
Poor
3. In your opinion, how would you rate the Applicant's current academic standing against other students in the same course/intake?
Top 1% Top 5% Top 10% Not in Top 10%
4. Is the Applicant suitable for the proposed course of study? Please give a brief comment on the candidate's strength and suitability.
5. Additional Comments:
I hereby confirm that the above information is true and accurate, to the best of my knowledge and belief.
Signature:
New NRIC:
Date:
SP/Page 5 of 6
Declaration by Applicant:
I hereby declare that: 1 All the information given in this Application Form and all the documents submitted are complete, true and correct. I authorise the Foundation to verify the information from whatsoever sources and by whatever means that the Foundation deems appropriate. 2 I understand that the Foundation reserves the right to forfeit my eligibility for the Scholarship or revoke any Scholarship approval granted to me or recall any Scholarship granted to me in the event that: a) any of the information, statement or fact disclosed in this Application Form is false or incorrect; or b) if there is any misrepresentation of information, statement or fact in this Application Form; or c) if any of the documents submitted in support of this application is falsified or forged. 3 I have never been made a bankrupt and there are no threatened, pending or existing bankruptcy proceedings commenced against me. I do not have any criminal record. I understand and accept that the Foundation reserves the right and has the absolute discretion to approve or reject my application without assigning any reason whatsoever and I accept all decisions by the Foundation as final and conclusive. The Foundation shall not be held responsible for any loss or delay in respect to this application.
4 5
Signature of Applicant Name: NRIC No:
Date
SP/Page 6 of 6

Ecm Libra Foundation: Application Form Scholarship Program

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ECM LIBRA FOUNDATION (671187-W)

Application Form Scholarship Program

PART I Personal Particulars

Old NRIC No:

House Tel No: Office Tel No:

Mobile No: E-mail Address:

College/Institution/University gained admission/applied to (Please attach Letter of Admission/Offer) : Name: Address:

Particulars of Spouse (if Applicant is married)

New NRIC No: Date of Birth: Gender: Race:

Old NRIC No: HP No:

PART II To be completed by Academic Referee

1. How long have you known the Applicant?

Signature of Applicant Name: NRIC No:

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