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MAHSA University College Haji Abdullah Scholarship Fund

APPLICATION FORM
Indicate your preference in applying to MAHSA University College programmes.
1st ____________________________________
* Medicine
* Nursing
* Medical Lab Technology

2nd ____________________________________

* Pharmacy*
* Biomedical Sciences
* Physiotherapy

3rd ____________________________________

Environmental Health & Safety

* Medical Imaging

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Part I: Personal Information
Name (as in MyKad):

Home Address:

Correspondence Address:

IC No.:

Date of Birth (dd/mm/yyyy)

Age:

Place of Birth : ___________________

Nationality: ___________________________________ Race: _________________________________

Contact No. :

mobile

years

House

Sex:

Male

Female

Email Address: ________________________________________________________________________________________________________________

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Part II: Family Background
No.

Name of Parents/Guardian & Siblings /Other Dependents

Relationship

Age

Occupation

Monthly Income

Part III: Education background

Name of school:

Address:

Tel. No.:

Highest Academic Qualification: (Please (x) and state year)

SPM

STPM

A-Levels

UEC

Matriculation

Others (Please state): _________________________

Subjects and Results

No

Subject

Grade

No

Subject

Grade

Note: Please produce certified true copies of relevant documents at the scholarship interview..
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Part IV: Extra Curricular Activities
No. Name of Club/ Society/ Association / Activities

Position

Year

Achievement

Please write briefly in less than 100 words to support your application
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Signature of Applicant

_______________
Date

For office Use

Decision & Recommendations:
______________________________________________________________________________________________________________________________
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Eligibility
Students who meet the following criteria may apply for the Haji Abdullah Scholarship Fund:
a) Malaysian Citizen
b) Age 24 years and less
c) Possess the following qualifications - SPM; STPM; UEC; A Levels; SAMS; Matriculation or equivalent
d) Good academic performance
e) Good Health
f) Family Financial position
Terms and Conditions - General
a) Students should meet the entry requirements as a full time student for the course elected
b) All information provided in the application form should be true and accurate, failing which the application may be revoked
without notice
c) All submissions should meet the timelines as set by MAHSA University College Haji Abdullah Scholarship Fund
d) Students should be able to furnish original documents and certified true copies on request by the University or at the interview.
Additional Terms and Conditions
a) Only shortlisted applicants will be notified by the University College
b) Where the student is required to attend an interview, this will be communicated to him/her stipulating the date, time and
venue of the interview.
c) Successful applicants will be informed by the University College through email within 4 weeks after the scholarship interview.
d) Students would be required to confirm acceptance of the scholarship award within 1 week of offer, failing which the offer of
scholarship will automatically lapse.
e) Scholarships awarded shall be based on actual results only. Provisional or forecast results will not be accepted.
f) Recipients of the scholarships would be required to sign an agreement with the University College and observe all terms and
conditions stated therein.
g) Successful scholarship recipients need to maintain a high academic performance and exemplary behaviour throughout their
study term at the University College.
h) Recipients of scholarships are encouraged to participate in the Universitys sports, extracurricular and other relevant activities.
i) Students receiving the scholarships will be encouraged to participate in selected community projects as and when required.
Time allocated shall be at the discretion of the Faculty Head.
j) The Scholarship awarded to the student shall not be transferable nor exchangeable for cash.
k) Students shall agree to pay any other miscellaneous fees which are not covered by the Scholarship Award.
l) Should the recipient of the scholarship decide to withdraw from the scholarship he/she will agree to pay back the scholarship
award amount consumed up to date.
m) The decision made by the Scholarship Selection Committee is final and no appeals shall be entertained.
n) MAHSA University College Abdullah scholarship fund reserves the right to stipulate the number of Scholarships to be awarded
for each programme.
o) The scholarship award may be revoked at any time in the event of gross misconduct or failure to meet the required academic
grades by the student in each year. In such an event, the recipient of the scholarship shall reimburse the University College
immediately the amount of scholarship received up to the date of revocation.
DECLARATION BY APPLICANT
I hereby declare that the information provided in this application form is true and correct. I have read the information and all terms
and conditions stipulated herein this application form, and agree that MAHSA University College reserves the right to change the
selection criteria and Scholarship policy without prior notification. The final decision to award the scholarship is at the sole discretion
of MAHSA University College. MAHSA University College further reserves the right to withdraw the scholarship should information
furnished in the application be found to be false, misleading or untrue.

_________________________________________
Signature of Applicant
Name:
MyKad no.:
Date:

Document Checklist (To be completed by applicant)

Documents
Completed application form
Recent Passport-size photo
Certified true copy of MyKad
Certified true copy of parents/ guardians MyKad
Latest Form J (Income Tax Returns Form) / EA Form / Pay Slip of Parents/Guardian and Siblings
Certified true copies of SPM / O-Levels / UEC / STPM / A-Levels / SAM / CPU / Matriculation / Diploma or any relevant
examinations results transcripts
Testimonials and Recommendations
Extracurricular Certifications, etc.