TITIJAYA

Recent passport-
SCHOLARSHIP size photograph
of applicant
FUND
PART A : PARTICULAR OF APPLICANT
Name (as per NRIC) :
Identity Card Number : Age : Gender :
Date of Birth : Citizenship :
Home Address :

Correspondence Address (if different from the above) :

e-mail address :
Contact No (residence) : Mobile No :
st
1 Year Student 2nd Year and Above Student
Present Student ID No. :
Status If not first year student, please state year of course in coming session :

If currently employed (permenant or temporary) , please state occupation :

No of months / years in employment :

Last drawn salary per month :
Is / Are your parent employee(s) of Titijaya Group of Companies Yes No
If yes, please state name of the person :

PART B : PARTICULAR OF COURSE PURSUING

Course attending :
Name of University :
Location :
Date of Commencement : Duration :
Amount per annum which can be obtain from family / other sources (in RM)

* please enclose the acceptance letter from the relevant university

PART C : FAMILY PARTICULARS
Parents
Name of Father / Gurdian* : Age :
Identity Card No : Contact No :
Occupation : Name of Employer :
Salary / Income /Pension (RM per month) :
*delete accordingly

Name of Mother / Gurdian* : Age :

Identity Card No : Contact No :
Occupation : Name of Employer :
Salary / Income /Pension (RM per month) :
*delete accordingly

Siblings (excluded applicant)

Name Relationship Age Occupation Gross Income
1)
2)
3)
4)
5)
6)
7)
8)

Do you have a sibling who is currently or was previously a recipient of the TITIJAYA scholarship?
If yes, please provide sibling's name :
No

PART D : LANGUAGES
Languages Speak Write Read
1)
2)
3)
4)
5)
PART E : EDUCATION BACKGROUND
Schools Attended From To Result
1)
2)
3)
4)
5)
* please enclose a copy of SPM, SPM (V), STPM, A Level result

If you are a second year or above student, please fill in the overall grade.
First Year Second Year Third Year

* please enclose a copy of university examination result slip

PART F : EXTRA CURRICULAR ACTIVITIES

Society/ Club/Other Activities From To Highest Position Held
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
* please enclose a copy of certificate, testimonials

Type of Sports / Games Year Level Representing

1)
2)
3)
4)
5)
6)
* please enclose a copy of certificate, testimonials
PART G : REFEREES
1) Name : NRIC :
Contact No : Occupation
Relationship : Years Known :

2) Name : NRIC :
Contact No : Occupation
Relationship : Years Known :
* Please do not select members of the family or relatives as Referees

PART H : PERSONAL MOTIVATION/OBJECTIVES

* In not more than 200 words, tell us about your personal motivation / career aspiration
PART I : OTHER INFORMATION & DECLARATION
Please state other relevant information to support your application expenses.

I the undersigned, declare that the information given by me in this form is true to the best of my
knowledge and that I have not willfully suppresses any material fact relevant to this application.
I have read and agreed to be abide by the terms and conditions of the scholarship/ financial assistance.
I understand that the scholarship herein can be withdrawn at any time if any information given in this
found to be incorrect. I have read and understood the conditions of the awards as stated in the
application form and the attached Terms and Conditions.

Applicant’s Signature Date

PART J : DOCUMENT CHECKLIST

Have you enclosed certified copies of Yes No

1. University acceptance letter

2. Parents’ / Guardian’s proof of income for the past 2 years
3. Brothers’ and sisters’ proof of income for the past 2 years, if they are working
4. Letters or documents to prove that brothers and sisters are pursuing higher
education in universities / colleges / institutions
5. Identity card and birth certificate of applicant
6. Birth certificates of all brothers and sisters
7. Parents’ / Guardian’s identity cards
8. SPM / SPVM / ‘O’ Level results
9. STPM / ‘A’ Level / Matriculation results
10. University / College / Polytechnic results
11. School testimonials
12. School leaving certificates

* please tick ( √ ) either “Yes” or “No”.

 FOR OFFICE USE ONLY
Preliminary Selection

Shortlisted K.I.V Rejected

Checked by Verified by
Date : Date :

Interviewed by Scholarship Committee on __________________ by the following :

(1) _______________________ (2) ________________________ (3) ________________________

Accepted K.I.V Rejected

Recommendation :

Approved for scholarship on behalf of TITIJAYA SCHOLARSHIP FUND

Approved by Date

Home Visit Conducted on ________________ by :

(1) _______________________ (2) ________________________ (3) ________________________

Mentor Assigned :

Name : ____________________________ Company/Division : ________________________