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8/11/2019 D Internet Myiemorgmy Iemms Assets Doc Alldoc Document 5704 Form
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THE INSTITUTION OF ENGINEERS, MALAYSIABangunan Ingenieur, Lots 60 & 62, Jalan 52/4, P.O. Box 223, Jalan Sultan, 46720 Petaling Jaya
Tel: 03-79684001/4002 Fax: 03-79577678 e-mail: [email protected] Homepage:http//www.iem.org.my
APPLICATION FOR
SCHOLARSHIP OFIEM EDUCATION FUND
Photo
1. NAME ………………………………………………………………………….…..………………
DATE OF BIRTH …………………... (D/M/Y) SEX ………… AGE ……………………
2 IDENTITY CARD NO. (NEW) ………………….. - ..…… - …..……… (OLD) …………….………
3 UNIVERSITY …………………………………………………………………………………………..….
4 CURRENT YEAR OF
STUDY
…………………..
(1, 2, 3, 4)
ENGINEERING
DISIPLINE
………………………………..………
Session: 20 ………../ 20……..…
5 SPM EXAMINATION RESULTS : Year sat : ……………… Division (Bahagian) ………………….
Subject Grade Subject Grade
……………………………………………………….…... ……………………………………………………………..
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additional paper : Year taken ………………………… …………………………………………………………….
6 STPM/DIPLOMA* EXAMINATION RESULTS
Subject Year sat Paper Grade Alphabet Grade
……………………………………………………………………………..……………………………………………….
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(d) Particulars of two Referees with whom the IEM can check on your character and family background
Name Occupation Address & Telephone No.
1. ……………………………………………………………………………………………………………………….
……………………………………….…
………………………………………….
2. ……………………………………………………………………………………………………………………….
……………………………………….…
………………………………………….
(e) Provide any other information on your family financial status which may be helpful towards your scholarship
application:
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12 YOUR PERMANENT HOME ADDRESS
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
Telephone No. (house) ……………………….… (office) …………………..… (mobile) ………………….
YOUR LOCAL CORRESPONDENCE ADDRESS (POSTAL ADDRESS)
………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………
Telephone No. (house) ……………………….… (office) …………………..… (mobile) ………………….
13 DECLARATION
I certify that the information provided in this application is to the best of my knowledge true and correct.
I understand that should any information so provided be found false, my scholarship if approved would be
cancelled and repayable to the IEM forthwith.
I declare I am also not the Recipient of any scholarship, loan, bursary, etc, for the current course of study in
which I am undertaking.
……………………………………
(Date)
………………………………………
(Signature of Applicant)
NOTE TO APPLICANT
Please refer to the Check-list and submit application to reach before deadline announced, to:
HON. SECRETARY
IEM BOARD OF EDUCATION FUND
C/o The Institution of Engineers, Malaysia
Bangunan Ingenieur,
Lots 60 & 62, Jalan 52/4,
P.O.Box 223, (Jalan Sultan),
46720 Petaling Jaya,
Selangor Darul Ehsan.
Telephone No. 6-03-79684001 or 6-03-79684002
Fax No. : 03 – 7957 7678
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THE INSTITUTION OF ENGINEERS, MALAYSIA
APPLICATION FOR
SCHOLARSHIP OF IEM EDUCATION FUND
Check List
√ …………………. Item (one each)
…………………. University admission letter (certified copy)
…………………. Certification letter from Faculty (see below)
…………………. Birth Certificate and Identification Card (certified copy)
…………………. SPM Examination result slip(s) (certified copy)
…………………. STPM/Diploma Examination result slip(s) (certified copy)
…………………. University academic transcripts (certified copy)
…………………. Other qualifications & awards (certified copy)
…………………. Latest J Form of Father / Guardian
…………………. Testimonials (certified copy)
Please inform the Institution of any change in your correspondence address
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UNTUK DI ISI OLEH WAKIL UNIVERSITI
Setiausaha KehormatInstitusi Jurutera MalaysiaBangunan Ingenieur
Lots 60 & 62, Jalan 52/4,P.O.Box 223, (Jalan Sultan),46720 Petaling Jaya,Selangor Darul Ehsan.
Dengan ini disahkan bahawa ………………………………………………………… (K/P: ………………………………………)
adalah pelajar berdafter : Bil: ………………………………………………………… di
Universiti :
Fakulti :
Jurusan :
Tahun :
Sessi :
Bilangan semester/penggal setahun akademik : ……………………………………………………………………………………...
Bayaran yuran berkenaan sesemester/penggal : ……………………………………………………………………………………...
……………………………
(Tarikh)
……………………………………………………………..
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