TOP GLOVE SDN BHD
SCHOLARSHIP FUND

APPLICATION FORM
FOR TOP GLOVE SCHOLARSHIP

INSTRUCTIONS

1. The application should be completed in writing by the applicant. An incomplete application will not be considered.
2. Only certified true copies of testimonials and certificates should be attached. The originals should be produced when called for an interview.
3. If necessary, due to space constraint, please attach addendum.
4. Please read carefully the declaration on item 17.
5. Please return completed form to.

TOP GLOVE Scholarship Fund
TOP GLOVE GROUP OF COMPANIES (F9)
LOT 4969, BT 6, JLN TERATAI, OFF JLN MERU,
41050 SELANGOR D.E. MALAYSIA.
Tel: 603-33921992 / 33921905
Fax: 603-33921291 / 33928410

PART 1- PERSONAL DETAILS
1. FULL NAME (Block Letters) Mr. Mdm. Miss :
2. (a) Correspondence Address (b) Tel. No.
     Mobile. No.
(c) Email Address
3. (a) Home Address if different
    from 2(a)		 (b) Tel. No.
4. (a) Date of Birth : (b) Place of Birth :
5. (a) Identity Card No :
    (old & new)		 (b) Place of Issue :
6. (a) International Passport No : (b) Place of Issue :
7. (a) Citizenship :      (b) Ethnic :      (c) Religion :
8. (a) Sex : Male  Female                     (b) Marital Status : Single  Married  Widow (er)  Divorced         
9. LANGUAGES : Indicate degree of fluency

Speaking

Writing
Good Fair Poor Good Fair Poor
1. Bahasa Malaysia
2. English
3.
4.
10. HEALTH
(a) Height :    (b) Weight :
(c) Any physical disability or handicap (e.g. sight, hearing, speech, etc.)
(d) Give details of any sickness which you may have suffered
11. NAME OF COURSES
(a) COURSES you would like to apply to study (in order of priority) i) 
ii)
(b) Explain why

PART II FAMILY DETAILS
12 (a) Father (b) Mother
i) Name :
ii) Nationality :
iii) Ethnic :
iv) Occupation :
v) Employer :
vi) Monthly Gross Income :
i) Name :
ii) Nationality :
iii) Ethnic :
iv) Occupation :
v) Employer :
vi) Monthly Gross Income :
(c) Brothers and Sisters
Name Age Relationship Occupation Employer ( School/College/University )
1.
2.
3.
4.
5.
(d) Relatives working in TOP GLOVE Companies in Malaysia
Name Relationship Occupation Location/Department
1.
2.
3.
4.
5.
13. INTERESTS AND SUPPLEMENTARY DETAILS
(a) Details of your Hobbies and Sporting Activities & offices held.
i)  
ii)  
iii)  
   
(b) Details of your activities at School/Colleges/Universities e.g. Societies, Teams, College, offices held etc.
i)  
ii)  
iii)  
(c) Are you able to swim?

 Yes
 No
 

PART III WORKING EXPERIENCES
14. WORKING EXPERIENCES
Name of Employer Job Held

Period of Employment

 Earning p.m.
From To
1.
2.
3.
4.
15. (a) Are you presently receiving financial assistance from any institution/foundations ? Yes No
If yes, give details
(b) Are you presently bonded to any scholarship sponsors ? Yes No
If yes, give details

PART IV EDUCATION DETAILS
16 (a) School Attended (starting from primary school)
Name of School From To Standard Reached
1.
2.
3.
4.
5.

Your stream of study: Science Art
(b) University/College/Institute or Polytechnic
Institutions Year Discipline (Major) Degree/Diploma
1.
2.
3.
(c) ©Certificates obtained: SRP/SPM/STPM/Matriculations, etc.
Examination: Examination: Examination:
Year Taken: Year Taken: Year Taken:
Subjects Grade Subjects Grade Subjects Grade
1.
2.
3.
4.
5.
6.

 Grade:

 Aggregate:

 Grade:

 Aggregate:

 Grade:

 Aggregate:
17. DECLARATION

I DECLARE THAT ALL PARTICULARS GIVEN ABOVE ARE TRUE AND CORRECT. I UNDERSTAND THAT NO CONSIDERATION WILL BE GIVEN TO MY SCHOLARSHIP AWARD OR IN THE CASE OF SCHOLARSHIP THAT HAS BEEN OFFERED, IT WILL BE IMMEDIATELY CANCELLED, IF ANY OF THE PARTICULARS GIVEN ARE FALSE.

I AM ALSO AWARE THAT COMPLETING AND SUBMITTING THIS FORM IS NO GUARANTEE OF ANY ASSISTANCE WHATSOEVER FROM TOP GLOVE SCHOLARSHIP FUND.
 
APPLICANT’S SIGNATURE Headmaster/Head of Department/Institute/College/University


 		  
____________________________________________ Signature:________________________________________________
Date:________________________________________ Name:___________________________________________________
  Date:____________________________________________________

FOR OFFICE USE ONLY

 Date received :___________________________________________
Acknowledge Date:________________________________________
Application Is Recommended / Not Recommended for consideration
Interview Date:____________________ Venue ____________________Time:_________________
Successful / Unsuccessful
Notification Date:_________________________
Remarks Date:___________________________
 
_____________________________________ _____________________________________ __________________________________
Signature of Interviewers Name Date (s)
 
 

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