Yayasan Form

BORANG PERMOHONAN ANUGERAH KECEMERLANGAN AKADEMIK

AFFIX PASSPORT SIZE PHOTOGRAPH HERE (LEKATKAN GAMBAR BERUKURAN PASPOT DISINI)

APPLICATION FORM ACADEMIC EXCELLENCE AWARD

ARAHAN/INSTRUCTION: SILA ISI DENGAN MENGGUNAKAN HURUF BESAR DI BAHAGIAN A HINGGA E/ PLEASE USE CAPITAL LETTERS IN FILLING PART A TO PART E. TANDA (√) JIKA BERSESUAIAN/ TICK (√) WHERE APPLICABLE.

TAHAP PENCAPAIAN PEMOHON / APPLICANT’S LEVEL OF QUALIFICATION SPM

STPM

Diploma

A : MAKLUMAT PERIBADI / PERSONAL INFORMATION 1.

Nama / Name:

2.

No. Kad Pengenalan / NRIC: -

3.

Tarikh Lahir / Date of birth: /

d

4.

6.

7.

-

d

/ m

m

Jantina / Gender

y

y

y

y

5.

Taraf Perkahwinan / Marital Status

Lelaki / Male

Bujang / Single

Perempuan / Female

Berkahwin / Married

Bangsa / Race Melayu / Malay

Bumiputera Sabah

India / Indian

Bumiputera Sarawak

Cina / Chinese

Lain-lain / Others: _______________

Alamat Surat Menyurat / Postal Address:

Alamat / Address:

Bandar / City:

8.

Negeri / State:

Poskod / Postal Code:

Pejabat / Office

Bimbit / Mobile

Telefon / Phone:

Rumah / Home

9. Alamat E-mel / E-mail address:

10. Alamat Tetap, jika berbeza daripada di atas / Permanent Address, if different from the above: Alamat / Address:

Bandar / City:

Negeri / State:

Poskod / Postal Code:

B: MAKLUMAT IBUBAPA/ PENJAGA/ DETAILS OF PARENTS / GUARDIAN 1.

Nama Bapa / Father’s Name:

2.

Kad Pengenalan / NRIC: -

3.

-

Jenis Pekerjaan / Type of Occupation:

4.

Pendapatan bulanan / Monthly income:

Kerajaan / Government Swasta / Private Bekerja Sendiri / Self employed Tidak Bekerja/ Unemployed 5.

Telefon / Phone:

Rumah / Home

Pejabat / Office

6.

Nama Ibu / Mother’s Name:

7.

Kad Pengenalan / NRIC: -

8.

Bimbit / Mobile

-

Jenis Pekerjaan / Type of Occupation:

9.

Pendapatan bulanan / Monthly income:

Kerajaan / Government Swasta / Private Bekerja Sendiri / Self employed Tidak Bekerja / Unemployed 10. Telefon / Phone: Rumah / Home

Pejabat / Office

Bimbit / Mobile

11. Nama Penjaga / Guardian’s Name:

12. Kad Pengenalan / NRIC: -

-

13. Jenis Pekerjaan / Type of Occupation:

14.

Pendapatan bulanan / Monthly income:

Kerajaan / Government Swasta / Private Bekerja Sendiri / Self employed Tidak Bekerja/ Unemployed 15. Telefon / Phone: Rumah / Home

Pejabat / Office

Bimbit / Mobile

16. Bilangan Tanggunggan / Number of Dependents: Nama/ Name

Jantina/ Gender

Umur/ Age

Perhubungan/ Relationship

Status Tanggunggan (Bersekolah/bekerja/lain-lain)/ Dependents Status (School/Working/Other)

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Anak-anak yang masih lagi menjadi tanggungan ibubapa/penjaga / Children who are still dependents of parents /guardian.

C: KELAYAKAN AKADEMIK/ ACADEMIC QUALIFICATIONS 1.

Sila nyatakan butiran kelayakan akademik anda / Please provide details of your academic background.

Nama Universiti / Institut Name of University / Institution

Tahun/ Year

Kelayakan/ Qualification obtained

Keputusan (PNGK)/ Result (CGPA)

Sila sertakan salinan sijil yang disahkan / Please attached certified copies of your certificates

STPM (Sila senaraikan semua subjek / Please specify all subjects) Nama Sekolah / School’s name: Matapelajaran / Subject

Gred / Grade

Matapelajaran / Subject

Gred / Grade

Sila sertakan salinan sijil yang disahkan / Please attached certified copies of your certificates

SPM (Sila senaraikan hanya subjek-subjek yang mendapat Gred A / Please only specify subjects with Grade A) Nama Sekolah / School’s name: Matapelajaran / Subject

Gred / Grade

Matapelajaran / Subject

Gred / Grade

Sila sertakan salinan sijil yang disahkan / Please attached certified copies of your certificates

D : AKTIVITI KO-KURIKULUM DAN KEGIATAN LUAR/ CO-CURRICULAR ACTIVITIES Mewakili/ Representing

Jawatan / Tahap Penglibatan / Aktiviti Position/Level of Involvement/Activity

Tahun/ Year

Keahlian atau jawatan-jawatan yang disandang di dalam persatuan atau taraf penglibatan dalam aktiviti ko kurikulum di peringkat Sekolah, Universiti, Daerah, Negeri, Kebangsaan atau Antarabangsa / Membership or position held or level of achievement in co curricular activities at School, University, District, State, Country, National or International levels. -3–

Contoh: Ketua Pelajar, Pengawas, Pustakawan, Pemain bolasepak dan lain-lain. / Examples: Head Prefect, Prefect, Librarian, Football team member and others.

E : PROGRAM PILIHAN DI UNIVERSITI TUN ABDUL RAZAK/CHOICE OF PROGRAM AT UNIVERSITI TUN ABDUL RAZAK

1. 

Sila tandakan () program yang anda ingin daftar di Universiti Tun Abdul Razak/ Please tick () programme you wish to register at Universiti Tun Abdul Razak; Programme Name



Programme Name

Foundation in Business Administration

Bachelor of Education

Foundation in Management

Bachelor of English

Foundation in Information Technology

Bachelor of Management

Bachelor of Business Administration

Bachelor of Information Technology

Bachelor in Accounting

Bachelor of Information System

Bachelor of Hospitality Management

Bachelor of Software Engineering

F : PENGAKUAN PEMOHON / APPLICANT DECLARATION Adalah saya dengan ini, mengaku bahawa maklumat yang diberi di atas adalah benar dan saya faham akan syarat asas permohonan yang telah ditetapkan oleh pihak pengurusan. Pihak Yayasan PINTAR berhak untuk mengambil tindakan membatalkan permohonan ini sekiranya didapati maklumat yang diberi adalah tidak benar. I hereby solemnly acknowledge that all information furnished above is true and I understand the terms and conditions of the Award as determined by the Management. Yayasan PINTAR reserves the right to revoke my application if any information is found to be false. Jika saya tidak menerima sebarang jawapan dari pihak Yayasan, 60 hari dari tarikh tutup permohonan, saya boleh mengandaikan bahawa permohonan saya tidak berjaya. If I did not receive any response from Yayasan, 60 days after the closing date, I can assume my application is not successful.

_________________________________ Tandatangan / Signature Nama / Name: Kad Pengenalan / NRIC No: Tarikh / Date:

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