APPLICATION FORM

A. CURRENT/OFFERED UNDERGRADUATE PROGRAMME AND UNIVERSITY DETAILS

1st Choice UNIVERSITY PROGRAMMEUKM NURSING

START DATE OF STUDY END DATE OF STUDY DURATION OF STUDY 2015 2018 4 YEARS

Note: Candidates are required to bring university offer letter during assessment if being shortlisted

2nd Choice UNIVERSITY PROGRAMME

START DATE OF STUDY END DATE OF STUDY DURATION OF STUDY

Note: Candidates are required to bring university offer letter during assessment if being shortlisted

B. SIJIL PELAJARAN MALAYSIA (SPM) DETAILS

SPM YEAR STATE ANGKA GILIRAN SCHOOL NAME

NO. SUBJECT GRADE

1

2

3

4

5

6

7

8

9

10

11

12

Note: Candidates are required to bring SPM result slip during assessment if being shortlisted

C. PREVIOUS ACADEMIC QUALIFICATIONS (A-LEVEL,AUSMAT, ADTP, ADFP, DIPLOMA,MATRICULATION,STPM, FOUNDATION, ETC.)

QUALIFICATION RESULT GRADUATE YEAR INSTITUTION

1.

2.

Note: Candidates are required to bring academic result transcript during assessment if being shortlisted

D. CURRENT UNDERGRADUATE RESULT

SEMESTER RESULT YEAR INSTITUTION

1.

2.

3.

4.

5.

Note: Candidates are required to bring latest academic transcript during assessment if being shortlisted

E. MUET/IELTS/TOEFL RESULT

TYPE OF ENGLISH CERTIFICATE YEAR RESULT

1.

2.

Note: Candidates are required to bring result slip during assessment if being shortlisted

PETRONAS Education Sponsorship Programme

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F. PERSONAL DETAILS

NAME (IC) :

IC NUMBER :

GENDER :

NATIONALITY :

RACE :

RELIGION :

MARITAL STATUS :

DATE OF BIRTH :

PLACE OF BIRTH (City) :

PLACE OF BIRTH (State) :

PLACE OF BIRTH (Country) :

G. MAILING ADDRESS

HOME ADDRESS :

CITY :

POSCODE :

STATE :

LENGTH OF STAY :

PHONE NUMBER :

MOBILE NUMBER :

EMAIL ADDRESS :

EMERGENCY CONTACT (NAME) :

RELATIONSHIP :

HOME ADDRESS :

CITY :

STATE :

PHONE NUMBER :

MOBILE NUMBER :

PETRONAS Education Sponsorship Programme

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H. DETAILS OF FAMILY/GUARDIAN

FATHER MOTHER GUARDIAN

FULL NAME (IC) :

IC NUMBER :

OLD IC NUMBER /ARMY/POLICE ID :

(If applicable)

EMPLOYER/COMPANY :

POSITION :

MONTHLY GROSS INCOME (RM) :

RELATIONSHIP :

IS FATHER/MOTHER/GUARDIAN STILL ALIVE? :

MARITAL STATUS :

I. NUMBER OF DEPENDENTS (FATHER/MOTHER/GUARDIAN)

NUMBER OF DEPENDENTS INCLUDING FATHER AND MOTHER:

NAME AGE RELATIONSHIP STATUS

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Note : If number of dependents are more than 10, please attach extra sheet

ARE YOUR SIBLINGS CURRENTLY RECEIVING EDUCATION SPONSORSHIP FROM PETRONAS?

IF YES, PLEASE GIVE DETAILS.

NAME IC NUMBER UNIVERSITY PROGRAMME

1.

2.

3.

Have you received any type of sponsorship? :

If yes, please state the sponsorship agency :

Start Date of Sponsorship :

End Date of Sponsorship :

PETRONAS Education Sponsorship Programme

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J. DECLARATION AND APPLICANT'S CONSENT

1. By submitting your details, you are allowing PETRONAS to use your personal data for the purposes of your application for the education sponsorship and/or the further usage of the same in the event you are successful in your application, including disclosing such data to any education institution for the purposes of securing a placement.

2. The personal data collected shall be kept safely at PETRONAS and the data will be retained for a reasonable period or for as long as the law requires.

3. In the event you are unsuccessful in your application, PETRONAS shall destroy all personal data submitted by you, together with any other related documents submitted thereto.

4. The accuracy of the personal information depends to a large extent on the information you provide. Therefore, kindly update PETRONAS as and when your personal information provided earlier becomes incorrect or out of date by contacting us via the contact details stated in the provision below.

5. If at any time, you wish to withdraw such consent you have given for the usage of your personal data, you may contact us at edu_sponsorship@petronas.com.my for further action.

6. I hereby certify that all information and statements provided as above are true and correct. All photocopy of related certificates and documents will later be sent to support this application are valid as required. I hereby further certify that the PESP Selection Committtee has an absolute right to reject this application; or withdraw the PETRONAS Education Sponsorship offer at any time if there is any mistake or doubt to be found in any of information and /or statement provided thereto.

7. PETRONAS will not disclose any of your personal data collected herewith to any third party except where you have given PETRONAS permission to do so or when PETRONAS is required and/or allowed to do so by law

REGARDS,

SIGNATURE OF APPLICANT

NAME :

IC NO. :

DATE :

PETRONAS Education Sponsorship Programme

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