APPLICATION FORM

A. CURRENT/OFFERED UNDERGRADUATE PROGRAMME AND UNIVERSITY DETAILS

1st Choice

UNIVERSITY

PROGRAMME
UKM

START DATE OF STUDY

DURATION OF STUDY
2018

NURSING

END DATE OF STUDY

2015
4 YEARS

Note: Candidates are required to bring university offer letter during

assessment if being shortlisted

2nd Choice UNIVERSITY

START DATE OF STUDY

DURATION OF STUDY

PROGRAMME

END DATE OF STUDY

Note: Candidates are required to bring university offer letter during

assessment if being shortlisted

B. SIJIL PELAJARAN MALAYSIA (SPM) DETAILS

SPM YEAR

NO.

SUBJECT

STATE

ANGKA GILIRAN

SCHOOL NAME

GRADE

1
2
3
4
5
6
7
8
9
10
11
12
Note: Candidates are required to bring SPM result slip during assessment if
being shortlisted

C. PREVIOUS ACADEMIC QUALIFICATIONS (A-LEVEL,AUSMAT, ADTP, ADFP,

DIPLOMA,MATRICULATION,STPM, FOUNDATION, ETC.)

QUALIFICATION

RESULT

GRADUATE YEAR

INSTITUTION

1.
2.
Note: Candidates are required to bring academic result transcript during
assessment if being shortlisted

D. CURRENT UNDERGRADUATE RESULT

SEMESTER

RESULT

YEAR INSTITUTION

1.
2.
3.
4.
5.
Note: Candidates are required to bring latest academic transcript during
assessment if being shortlisted

E. MUET/IELTS/TOEFL RESULT

TYPE OF ENGLISH CERTIFICATE

1.
2.

YEAR

RESULT

Note: Candidates are required to bring result slip during assessment if being
shortlisted

PETRONAS Education Sponsorship Programme

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F. PERSONAL DETAILS

NAME (IC)

IC NUMBER

GENDER

NATIONALITY

RACE

RELIGION

MARITAL STATUS

DATE OF BIRTH

PLACE OF BIRTH (City)

PLACE OF BIRTH (State)

PLACE OF BIRTH (Country)

G. MAILING ADDRESS

HOME ADDRESS

CITY

POSCODE

STATE

LENGTH OF STAY

PHONE NUMBER

MOBILE NUMBER

EMAIL ADDRESS

EMERGENCY CONTACT (NAME)

RELATIONSHIP

HOME ADDRESS

CITY

STATE

PHONE NUMBER

MOBILE NUMBER

PETRONAS Education Sponsorship Programme

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H. DETAILS OF FAMILY/GUARDIAN

FATHER

FULL NAME (IC)

MOTHER

GUARDIAN

IC NUMBER

OLD IC NUMBER /ARMY/POLICE ID

(If applicable)

EMPLOYER/COMPANY

POSITION

MONTHLY GROSS INCOME (RM)

RELATIONSHIP

IS FATHER/MOTHER/GUARDIAN STILL ALIVE?

MARITAL STATUS

I. NUMBER OF DEPENDENTS (FATHER/MOTHER/GUARDIAN)

NUMBER OF DEPENDENTS INCLUDING FATHER AND MOTHER

:

NAME

AGE

RELATIONSHIP

STATUS

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Note : If number of dependents are more than 10, please attach extra sheet

ARE YOUR SIBLINGS CURRENTLY RECEIVING EDUCATION SPONSORSHIP FROM

PETRONAS?

IF YES, PLEASE GIVE DETAILS.

NAME
1.
2.
3.

IC NUMBER

UNIVERSITY

PROGRAMME

Have you received any type of sponsorship?

If yes, please state the sponsorship agency

Start Date of Sponsorship

End Date of Sponsorship

PETRONAS Education Sponsorship Programme

Page 3 of 4

J. DECLARATION AND APPLICANT'S CONSENT

1. By submitting your details, you are allowing PETRONAS to use your

personal data for the purposes of your application for the education sponsorship
and/or the further usage of the same in the event you are successful in your
application, including disclosing such data to any education institution for the
purposes of securing a placement.

2. The personal data collected shall be kept safely at PETRONAS and the data
will be retained for a reasonable period or for as long as the law requires.

3. In the event you are unsuccessful in your application, PETRONAS shall

destroy all personal data submitted by you, together with any other related
documents submitted thereto.

4. The accuracy of the personal information depends to a large extent on the

information you provide. Therefore, kindly update PETRONAS as and when your
personal information provided earlier becomes incorrect or out of date by contacting
us via the contact details stated in the provision below.

5. If at any time, you wish to withdraw such consent you have given for the
usage of your personal data, you may contact us at
edu_sponsorship@petronas.com.my for further action.

6. I hereby certify that all information and statements provided as above are
true and correct. All photocopy of related certificates and documents will later be
sent to support this application are valid as required. I hereby further certify that the
PESP Selection Committtee has an absolute right to reject this application; or
withdraw the PETRONAS Education Sponsorship offer at any time if there is any
mistake or doubt to be found in any of information and /or statement provided
thereto.

7. PETRONAS will not disclose any of your personal data collected herewith to
any third party except where you have given PETRONAS permission to do so or

when PETRONAS is required and/or allowed to do so by law

REGARDS,

SIGNATURE OF APPLICANT

NAME :

IC NO. :

DATE :

PETRONAS Education Sponsorship Programme

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