BN YOUTH Recent

EDUCATION SCHOLARSHIP Photograph

For Academic Year ___________

Course Applied For: Name of Institution

.............................................................................................................. .......................................................................

Section A Personal Details

Full Name (as in IC):

Residential Address:

............................................................................................................................................................................................................................................................
.......................................................................................................................................................................................... Post Code :...........................................
House Tel: ..................................................................... Handphone No:..................................................... Email Address:............................................................

Nationality: Race: Religion:

Date of Birth: Identity Card No:

................ / ................. / ............... Sex: Male Female (New) ......................................................................

Marital Status: Languages:

Single Married Spoken: Written:

Section B Educational Qualifications

SPM / SPVM / STPM / “A”Levels / Diploma Examination Results
Name and Address of School: Year Taken:

Tel:

Subject Grade Subject Grade

Section C Extra-Curricular Activities / Reason(s) for Applying

On a separate sheet of paper, please provide

a) Details of extra-curricular activities, including membership of societies / associations.

b) State briefly your reason(s) for applying.

Section D Family Background
Father / Guardian
Name: Age: I/C No:
Home Address: House:
Family Owned
Rented
Tel:
Name and Address of Employer: Occupation:

Tel: Annual Gross Income ( last year ):

Mother
Name: Age: I/C No:
Name and Address of Employer: Occupation:

Tel: Annual Gross Income ( last year ):

Section E Referees
Give names, addresses and occupations of two (2) referees (not related to the applicant)
Name: (Dr./Mr./Mrs./Ms) Name: (Dr./Mr./Mrs./Ms)

Address: Address:

Tel: Tel:

Occupation: Occupation:

Are you presently enrolled at any University/College: ( YES / NO )

If “yes”, please provide the following information:
Name of educational institution: ..........................................................................................................
Name of the course and year enrolled: ..........................................................................................................

Section F Application Procedure:

Print clearly or write legibly. False particulars or wilful suppression of material facts will render you liable to disqualification. All required documents
must be submitted with application.
Note: Proof of posting is not proof of receipt.
Address application form to: BNYES Secretariat,
Lot 3.03, 3rd Floor, Bangunanan KWSP,
Changkat Raja Chulan,
Off Jalan Raja Chulan, 50200 Kuala Lumpur.
Applicants must meet the following conditions:
• Malaysian citizens below 25 years of age as on 1st January this year.
• Possess good results in SPM/STPM or other equivalent qualifications.
• Be active in sports and extra-curricular activities.
• Must not be bonded to or in receipt of any financial aid or rewards from other educational institutions or organisations.
• Must be able to gain admission to approved educational institutions.

The scholarship award is not a cash award but will be in the form of academic course to be offered by the participating colleges / institutions
of higher learning / universities with the tuition fee and / or such other incidental expenses fully paid up.
PLEASE ATTACH A COPY OF THE FOLLOWING DOCUMENTS.

Identity Card (both sides) SPM / SPVM / STPM / ‘A’ Level / Other
Equivalent Qualifications.
Testimonial(s) and Record(s) of Participation in
Extra-curricular Activities Supporting document(s) on financial status

Birth Certificate

DECLARATION BY APPLICANT
I recognise that the information constitutes representations to you whereby your judgement may be based. If at anytime
hereafter you were to find such information materially false / untrue or if there is any omission, you shall be at liberty to
take such action against me and my guarantor(s) including termination of any benefit granted me and recovery of any
benefit hitherto extended me and all costs thereby incurred shall be borne by me.

I recognise that if any award is not a direct grant of BN Youth Education Scholarship (BNYES) but is granted by any other
sponsor / donor / educational institution or any corporation, person or organisation through BNYES , any subsequent
failure to contribute, any discontinuance or termination, suspension or variation shall not be the responsibility of
BNYES and I hereby agree to waive any right of action(s) against BNYES.

I undertake to complete the course of study with diligence and within minimum time, to report to you and to furnish you
progress reports / term results immediately upon their issuance to me and all receipts for payment of fees and incidental
expenses.

I understand that I may have to execute a scholarship bond and to furnish you suitable guarantor(s) or form of security that

I confirm that I have read all the terms and conditions in respect of this application and I hereby agree to be bound by the
same.

Name: ............................................................................................. I/C No:........................................................................

Signature: ....................................................................................... Date: ..........................................................................