SECTION A: APPLICANT S PARTICULARS

Transcription

1 Recent photograph of yourself SPECIAL MALAY BURSARY Application Form INSTRUCTIONS 1. Please write clearly and legibly using BLOCK letters. 2. All columns must be filled in the spaces provided. A NIL or N.A. entry must be written wherever not applicable. 3. Tick the appropriate boxes where necessary. 4. Completed forms without proper supporting documents will not be processed. 5. Completed forms are to be returned to Education Dept, Wisma MENDAKI, 51 Kee Sun Ave, Singapore SECTION A: APPLICANT S PARTICULARS 1. Full Name (Block letters as in NRIC): 2. Address: 3. House Type: 4. Telephone: Home: Mobile: Postal Code: 5. Date of Birth: / / 6. Gender: 7. NRIC No: 8. Race: 9. Religion: 10. Citizenship: 11. Marital Status: Address: 12. Institution: 13. Country: 14. Course of Study: 15. Duration of Study: Yrs Mths *Explanatory Notes 3.House Type HDB 3-Rm & below 1 HDB 4-Rm 2 HDB 5-Rm 3 HDB Executive 4 Private Property 5 6.Gender Male Female 8.Race Malay 1 Indian 2 Chinese 3 Arab 4 Others 5 M F 10.Citizenship Singapore Citizen 1 Permanent Res 2 Others 3 11.Marital Status Single 1 Married 2 Divorced/Widowed Year of Study: (*1 st /2 nd /3 rd /4 th /5 th ) 17. Commencement Date: 18. Completion Date: / / / / 19. Amount of Tuition Fee required to complete the course: **S$ 20. State whether you were exempted from paying your school fees in your secondary/preuniversity school/college: Yes No *Delete where not applicable **Please attach supporting documents 1

2 SECTION B: EDUCATIONAL RECORDS 1. List the School/Junior College attended from Secondary 1. School/Junior College Date of Joining Date of Leaving Highest Standard Passed Year 2. Detailed GCE O level examination results or equivalent. Name of School: Year: Year: Subjects Grade Grade 2

3 3. Detailed GCE A level examination results or equivalent. Name of School: Year: Year: Subjects Level Grade Level Grade NOTE: Please ensure that your best set of results and your best grade for Second Language are included. SECTION C: ACADEMIC QUALIFICATIONS Please enter N.A if this section is not applicable to you. List in chronological order of your qualifications. Name the Certificate, Diploma, Degree or Professional Qualification received Name of Institution Year of Award 3

4 SECTION D: EXTRA CURRICULAR ACTIVITIES (in school, university or others) Name of Societies, Committees or Association joined Level of Participation Year SECTION E: PRESENT EMPLOYMENT DETAILS Current Designation: Years at this position: From: / mm yy Company Name: Company Address: Singapore Telephone: Ext: Fax: National Service status (Please one of the boxes where applicable) 1 I am not liable for NS Yes No 2 I have served NS Yes No Date of Enlistment : Run out Date : Rank : Unit : Vocation : 3 I am/will be *serving NS Yes No Date of Enlistment : Run out Date: Rank : Unit : Vocation : 4 I have been exempted from NS Yes No Reason(s): 4

5 SECTION F: PAST EMPLOYMENT RECORD In chronological sequence, starting with your most recent position. Name of Company Designation* Gross Monthly Income From mth / yr Period From mth / yr No. of Years / Months Job Description (Responsibilities & Nature of work) No. of Staff reporting directly to you a) b) c) d) e) *Please indicate Full-time, Part-time or Temporary job Total number of years working experience (NS not included) years months 5

6 SECTION G: FAMILY PARTICULARS Enter particulars of immediate family members (parents and siblings). If you are married, include particulars of spouse and children. Name Relationship to Application Date of Birth Citizenship Marital Status Staying with Applicant? Yes / No Occupation Gross Monthly Income ($) Employer / School Attending 6

7 SECTION H: OTHER INFORMATION (please circle where appropriate) 1. Have you ever been convicted in a court of law of any country? Yes / No 2. Have you ever been dismissed, discharged or suspended from employment? Yes / No 3. Have you ever had, or are you suffering from any of the following:- - physical impairment? Yes / No - communicable disease? Yes / No - mental illness? Yes / No - medical condition? Yes / No 4. Have you undergone any surgical procedure? Yes / No 5. Name of friends / relatives in MENDAKI? Yes / No 6. Are you applying for Tertiary Tuition Fees Subsidy (TTFS)? Yes / No 7. Are you applying for MENDAKI Study Loan? Yes / No 8. Have you applied any other scholarships or bursary? If yes, Yes / No If answer if yes to any of the above question, please elaborate and/or submit supporting documents. SECTION I: DECLARATION BY APPLICANT 1. I hereby declare that the particulars contained in this application are true and correct and agree that they be the basis for selection for Yayasan MENDAKI. 2. I understand that the acceptance of this application form by Yayasan MENDAKI does not bind MENDAKI to approve the application and that MENDAKI is at liberty to reject the application without assigning any reason for so doing. 3. Approval shall be confirmed when I receive the letter of offer from MENDAKI. Applicant Signature Date 7

8 SECTION J: SURETIES SURETY 1 1. Full Name (Block letters) *Mr / Mrs / Miss: 2. Address: *Explanatory Notes 5.Gender Male Female M F 3. Telephone: Home Postal Code: 7.Citizenship Singapore Citizen 1 Permanent Res 2 Others 3 Mobile 4. Date of Birth: / / 5. Gender: 6. NRIC No: 8. Relationship to Applicant: 7. Citizenship: 9. Occupation: 10. Name & Address of Employer: Postal Code: Office Telephone: 11. Gross Monthly Income: 12. Are you standing as surety for any other person? Yes / No* Have you ever been made bankrupt or become insolvent? Yes / No* Are there any outstanding judgement/court cases against you? Yes / No If yes, please furnish details: SURETY 2 1. Full Name (Block letters) Mr / Mrs / Miss: 2. Address: Postal Code: 3. Telephone Home Mobile 4. Date of Birth: / / 5. Gender: 6. NRIC No: 7. Citizenship: 8. Relationship to Applicant: 9. Occupation: 10. Name & Address of Employer: Postal Code: Office Telephone: 11. Gross Monthly Income: 8

9 12. Are you standing as surety for any other person? Yes / No* Have you ever been made bankrupt or become insolvent? Yes / No* Are there any outstanding judgement/court cases against you? Yes / No* If yes, please furnish details: Declaration by Sureties I hereby declare that the information given in this application is true and correct, and that I have not willfully suppressed any material fact. Signature of Surety 1 Date Signature of Surety 2 Date *Delete where not applicable SECTION K: FOR OFFICIAL USE ONLY Checked By: Date: Verified By: Date: Remarks: (if any) Status: Approved / Not Approved Comments: 9

10 SECTION L: CHECKLIST I have submitted a photocopy of each of the following: Yes No N.A a) My birth certificate b) My identity card (NRIC) c) My GCE O level results/certificate d) My GCE A level results/certificate e) Letter of acceptance from Polytechnic or University OR Examination results OR Academic Transcripts f) My father s identity card g) My mother s identity card h) If not a Singapore citizen My Singapore Citizenship certificate by birth My father s Singapore Citizenship certificate My mother s Singapore Citizenship certificate i) Certificate(s) of Death j) Certificate(s) of Divorce / Remarriage k) Parents, siblings and/or spouse latest payslip, CPF statement or income tax assessment returns l) Sureties latest payslip and NRIC 10

11 DATA PRIVACY NOTICE 1. Yayasan MENDAKI is an organization that respects privacy. In the application form, we have requested for your personal information* (and your family members personal information where applicable). 2. To enable us to assist you effectively, your personal information may be collected, used or disclosed for the following purposes: (a) (b) (c) (d) (e) (f) (g) (h) evaluating your application; verifying background information; general administration in providing our services or assistance; monitoring of performance and compliance with terms of our services or assistance; offering other assistance provided by Yayasan MENDAKI; research and analysis for social assistance objectives; reviewing our policies for our services and assistance programmes; and any other purpose reasonable in connection with the above. 3. We may disclose your personal information to our related entities and affiliates (e.g MENDAKI SENSE Pte Ltd, MENDAKI Club, Community Leaders Forum (CLF)) or other third party service providers for the purposes stated above. We will require these related entities, affiliates and third party service providers to assure us that they will act in compliance with their personal data obligations and keep your personal information confidential. 4. If you have provided your family members personal information, you confirm that they have been informed of the contents of this notice and have consented to the collection, use or disclosure of their personal information for the purposes stated in this notice. 5. Do let us know if there are changes to the personal information you have provided so that we can update our records accordingly. 6. We will adopt appropriate security safeguards and measures to protect your personal information from unauthorized access, collection, use, disclosure, copying, modification disposal or other risks. 7. The terms of this notice shall be in addition to all other terms of the service or assistance that may be applicable to you. 8. You may also find more information about Yayasan MENDAKI s personal data protection policy at I agree to the contents of this notice and consent to the collection, use and disclosure of personal information as set forth in the notice. * If you are filling up this application form for your child/ward, all references to your personal information here shall refer to your child s/ward s personal information. Accordingly, any reference to your family members personal information shall refer to your child s/ward s family members personal information. Signature of Client : Name of Client : NRIC of Client : Date :