MOHE 2011

Please affix
Passport
size
Photograph
(2 copies)
MALAYSIAN INTERNATIONAL SCHOLARSHIP
(MIS)
(in duplicate)

FOR OFFICIAL USE ONLY

Reference no.:
Received:
APPLICATION FORMS
FORMS
(to be written by hand – block letters or word processed) Checked:

Course Applied:
UNDERGRADUA
UNDERGRADUATE STUDIES
(MIS SCHOLARSHIP)

POST-
POST-GRADUATE STUDIES
Name of the university in Malaysia:
❏ PhD ❏ Masters
( please mark X )

Proposed date of
commencement:

1. PARTICULARS OF APPLICANT
Family name (surname) Date of birth
Day Month Year
First Name Nationality ( citizenship) :

Other names Gender:

Male / Female #
City and country of birth Marital status:
Single / Married / Divorced / Widowed #
Passport No: Number of children :

Expiry date of passport: Religion:

Airport of departure to Malaysia :

# Delete accordingly

2. MAILING AND COMMUNICATION ADDRESS

( For notification of result)
Applicant's office name:
Applicant's Postal Address:
Postal address:
City:
City:
Country:
Country:
Home Country Area Number
telephone:

Office telephone Telefax Email

Country Area Number Country Area Number

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Person to be contacted in case of emergency, name, telephone and address:

3. EDUCATION (list in order of time, starting with last institution attended)

Name of institution and place of Major field of study Years of study: Master/Degree/ Grade or
study from - to Diploma/ CGPA
Certificate

4. ACADEMIC AND FINANCIAL AWARDS (e.g. Honours, distinction, book prizes, scholarship) won in the last 3
years. Please list in chronological order and submit copies of documentary evidence)

Year Type of Award ( For scholarship obtained, please indicate tenure and value of award)

5. OTHER ACTIVITIES (curricular activities)

Date / Duration Brief Description Position Held

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6. PREVIOUS RESIDENCE IN FOREIGN COUNTRY

Country Year Length of stay

Have you participated in any training programme in Malaysia before

❏ no ❏ yes

Name of programme, organizer, year

Have you participated in any MTCP training programme in Malaysia before

❏ no ❏ yes
Name of programme, organizer, year

Are you going to return home to your present job? YES / NO* If not, what job will you be doing?

7. FIELD OF STUDY

Please state briefly the reasons for applying to this course, your main fields of interest within the programme and how
you hope to benefit from the programme:

Please continue to supplementary pages if necessary

8. RESEARCH / PROJECT (For post-graduate application only)

Title:

Description / Abstract (not more than 200 words) - Please attach

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9. WORK EXPERIENCE (For post-graduate application only)
EMPLOYMENT RECORD It is important to give complete information. For each post you have occupied,
provide details of your duties and relevant sufficient references.

Current Job/Post: Description of your work including your personal

Responsibilities:
Dates From: to:

Title of your post:

Type of organization:

(Private/Government/Semi-Government)*
Name of employer:

Address of employer:

Monthly salary (USD):

Previous Job/Post:

Dates From: to:

Title of your post:

Type of organization:
(Private/Government/Semi-Government)*
Name of employer:

Address of employer:

Proficiency in Languages
Very good Fair Basic Nil

(a) English Spoken

Written

(b) Bahasa Malaysia Spoken

( Malay language)
Written

(c) Mother-tongue:

Recommendation from the Employer / Dean of Faculty/Head of School or College:

Signature :
Name :
Date: Designation:
Name of organization:

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10. DECLARATION
Have you ever been convicted by a Court of Law of any country ? Yes / No #
If yes, please give brief details:

I certify that my statements in answer to the foregoing questions are true, complete and correct to the best of my
knowledge and belief.

If accepted for a training award, I undertake to:-

(a) Carry out such instructions and abide by such conditions as may be stipulated by both the nominating
government and the host government in respect of this course of training;
(b) Follow the course of study or training, and abide by the rules of the University or other institution or
establishment in which I undertake to study or train;
(c) Refrain from engaging in political activities, or any form of employment for profit or gain;
(d) Submit any progress reports which may be prescribed

I also fully understand that if I am granted a scholarship award it may be subsequently withdrawn if I fail to make
adequate progress or for other sufficient cause determined by the host Government.

Signature of candidate:

Name:

Date:

# Delete accordingly

11. OFFICIAL DECLARATION (to be completed by the nominating government

government )

The Government of:

nominate
( name of applicant)

For the scholarship ( Academic Year 2011/12 ) under Malaysian International Scholarship and certifies that:

(a) all information supplied by the nominee is complete and correct;

(b) the nominee had adequate knowledge, appropriately tested of his/her English Language which can be used for
selection purposes in the proposed host country.

Remarks:

__________________________ ____________________________________________
( Name ) ( Signature of responsible Government official)

_______________________________________ Address of Department / Ministry:

( Designation)

Official Seal / Stamp:

Office Telephone number:

Office Fax number :
Date: E mail:

Please note: This application form must be duly completed and endorsed by the Ministry of Foreign Affairs or the relevant
agency responsible for the MIS Scholarship in your country. INCOMPLETE AND/OR UNENDORSED FORMS CANNOT BE
PROCESSED.

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