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新加坡福建会馆华文教学奖学金
SINGAPORE HOKKIEN HUAY KUAN CHINESE LANGUAGE SCHOLARSHIP
For Official Use Only
SECTION 1: PERSONAL PARTICULARS
Name (as in official document. Underline surname or family name)
Identity Card No
Sex
Race
Name in Chinese Character
Place of Birth
Country of Birth
Affix recent passportsized photograph
Date of Birth (DD/MM/YYYY)
Religion
Citizenship
Email Address (Please check regularly for notifications):
Passport No
Date of Issue (DD/MM/YYYY)
-
Home Address (In Malaysia)
Telephone Number (Home)
Country / State Code:
Handphone Number (in Malaysia):
Handphone Number (in Singapore):
SECTION 2(A): EDUCATIONAL BACKGROUND
For Current Undergraduates in a Singapore university, please indicate your GPA score:
Name of Pre-University (In Malaysia)
Highest Level of Study
Pre-University Results
Year & Name of Examination:
Level of Study:
Subject
1. English Language
Marks / Grade
Marks / Grade
2. Malay Language
3. Chinese Language
4.
5.
6.
7.
8.
9.
10.
11.
12.
Position in Class/Standard
Class : (
/
) Standard : (
*Delete where applicable.
1
/
)
Class : (
/
) Standard : (
/
)
Name of Applicant : ________________________________
SECTION 2(B): EDUCATIONAL BACKGROUND
Language
Medium
Name of schools attended including the present school
(in chronological order)
Highest
Standard
Passed
Period of Study
(dd/mm/yy)
From
To
1
2
3
4
5
SECTION 3: FAMILY BACKGROUND
Father’s Particulars
Name
Date of Birth
-
-
Age
Citizenship
Country of PR
-
-
Age
Citizenship
Country of PR
(DD/MM/YYYY)
Occupation
Employer/Company
Mother’s Particulars
Name
Date of Birth
(DD/MM/YYYY)
Occupation
Employer/Company
Sibling’s Particulars (from the eldest to the youngest)
Name
No. of Brothers
1
Date of Birth
(DD/MM/YYYY)
-
-
Citizenship
-
-
Citizenship
-
-
Citizenship
Occupation
Employer/Co./Sch
Name
2
Date of Birth
(DD/MM/YYYY)
Occupation
Employer/Co./Sch
Name
Date of Birth
(DD/MM/YYYY)
3
Occupation
Employer/Co./Sch
2
No. of Sisters
Name of Applicant: ________________________________
SECTION 4: OUTSTANDING ACADEMIC ACHIEVEMENTS DURING PRE-UNIVERSITY
(Scholarships, honours, distinctions, book-prizes etc)
Type of Award (in chronological order)
Year
SECTION 5: EXTRA-CURRICULAR ACTIVITIES DURING PRE-UNIVERSITY
(Sports, scout/guide/cadet groups, clubs, societies etc. Also include leadership positions held eg prefect, monitor)
Name of Activity
(in chronological order)
Level of Participation
(School Representative, Treasurer, Member)
3
Year
Name of Applicant : ______________________________________
SECTION 6: OTHER INFORMATION
Have you applied to any institution of study in your home country or other countries (including Singapore) for your
undergraduate studies? If yes, please give details.
Date of Application
Institution
Country
Course of Study
Are you in receipt of or have you held a scholarships award? If yes, please give details:
Type/Name of Award
Period Held
Value
Outcome of
Application
Period of Bond, if any
Please give details of scholarships/bursaries (foreign and/or local) received by any of your siblings.
Name of
Recipient
Name of
Award
Country of
Award
Period
Held
Please indicate the university / undergraduate course you have been applied/offered admission for your studies,
commencing in AY 2015/2016.
Applied (Yes/No) Offered (Yes/No)
_____
_____
1
National University of Singapore [Bachelor of Arts]
2
Nanyang Technological University [School of Humanities and Social Sciences]
_____
_____
3
National Institute of Education [Bachelor of Arts (Education)]
_____
_____
1
Have you ever suffered or are you suffering from any physical impairment, disease or
mental/nervous disorders or have been referred for any psychiatric treatment for anxiety,
depression, stress, eating disorder etc?
2
3
4
5
* Yes / No
Do you have a criminal record in any country?
By this, we refer only a criminal record of a conviction under the Registration of Criminals Act.
* Yes / No
Have you ever been convicted in a court of law in any country (excluding parking offences or
criminal records disclosed above)?
* Yes / No
Are you under any current police investigations in any country following allegations made
against you?
* Yes / No
Have you been or are you under any financial embarrassment i.e.
a)
an undischarged bankrupt,
b)
a judgement debtor,
c)
have unsecured debts and liabilities of more than 3 months of last-drawn pay,
have signed a promissory note or an acknowledgement of indebtedness ?
If yes for any of the above questions, please give details below:
* Delete where applicable.
4
* Yes / No
Name of Applicant : ________________________________
SECTION 7: PARTICULARS OF RELATIVE / FAMILY FRIEND STAYING IN SINGAPORE
1
2
Do you have any relative/friend in Singapore?
If yes, please give particulars of the person below:
Name
Relationship
*Yes/No
Address
Citizenship
Occupation
Home Telephone No.
Office Telephone No.
SECTION 8: DECLARATION BY APPLICANT AND PARENT/GUARDIAN
1
I declare that the particulars provided in this application are true and that I have not wilfully suppressed any
material fact.
2
I understand that if any entry is false, my application will be rejected; and if I am awarded the scholarship,
the award will be withdrawn.
3
Certified copies of the supporting documents are attached.
Signature of
Applicant
* Delete where applicable.
Name & Signature of
*Father/Mother/Guardian
Closing date: 31/1/2015
All forms are to be submitted to:
via fax and/or post
Singapore Hokkien Huay Kuan
5 Sennett Road
Singapore 466781
Fax: (65) 6225 7303
5
Date