AIU-IRSYAD International School

AIU-IRSYAD International School PRIMARY SCHOOL / SEKOLAH RENDAH SCHOLARSHIP APPLICATION FORM / BORANG PERMOHONAN BIASISWA Applicant Photo / Gambar Pemohon PART 1: APPLICANT S (CHILD) PERSONAL DETAIL BAHAGIAN 1: MAKLUMAT PERIBADI PEMOHON (ANAK) Full Name (in capital letters) / Nama Penuh (huruf besar) : Gender / Jantina: Male / Lelaki Female / Perempuan Age / Umur: Weight / Berat: Height / Ketinggian : Birth Certificates No / No.Surat Beranak.: Date of Birth / Tarikh Lahir: Place of Birth / Tempat Lahir: Religion / Agama: Home Address/ Alamat Rumah: Citizenship / Warganegara: Race / Bangsa: *Name of school / kindergarten attended: *Nama sekolah / taska yang diikuti: Date of Entry (Month & Year): Tarikh Mendaftar (Bulan & Tahun): Date of End (Month & Year): Tarikh Tamat (Bulan & Tahun): *Please submit photocopied of kindergarten certificate of report book *Sila lampirkan salinan sijil atau buku laporan dari tadika Scholarship application for AIIS 1

PART 2 : FAMILY BACKGROUND BAHAGIAN 2: LATARBELAKANG KELUARGA Name of Father / Guardian: Nama Bapa / Penjaga: Identity Card No / No. Kad Pengenalan: Citizenship / Warganegara: Living / Hidup Deceased / Meninggal Dunia Occupation/ Pekerjaan: Monthly Income (RM) / Pendapatan Bulanan (RM): No. of Dependents / Jumlah tanggungan: Telephone No / No. Telefon: Home Address / Alamat Rumah: Name of Mother / Nama Ibu Identity Card No / No. Kad Pengenalan: Citizenship / Warganegara: Living / Hidup Deceased / Meninggal Dunia Occupation / Pekerjaan: Monthly Income (RM) / Pendapatan Bulanan (RM): No. of Dependents / tanggungan: Jumlah Telephone No / No. Telefon: Home Address / Alamat Rumah: Number of sibling / Bilangan adik Beradik: No Name / Nama Age / Umur Relationship / Hubungan Marital Status / Taraf Perkahwinan School / College / University Sekolah / Kolej / Universiti Occupation / Pekerjaan Income / Pendapatan (RM) Scholarship application for AIIS 2

PART 3: GENERAL INFORMATION (To be filled up by parents / guardian) BAHAGIAN 3: MAKLUMAT AM (Diisi oleh ibubapa / waris) 1. What are your reasons for applying for the Albukhary scholarship? Please describe your financial needs in full detail to justify the scholarship be given to your son/daughter. Apakah sebab-sebab utama anda memohon biasiswa Albukhary. Sila nyatakan keperluan kewangan anda secara terperinci bagi melayakkan anak anda mendapat bantuan biasiswa ini. 2. How will this scholarship help your children make a positive impact on his/her future? Bagaimanakah biasiswa ini dapat memberi kesan positif kepada masa depan anak anda? Scholarship application for AIIS 3

PART 4: DECLARATION BAHAGIAN 4: PENGAKUAN E. DECLARATION I, I/C number, parent of hereby confirm that I have personally filled in this Application Form and the information given by me is accurate to the best of my knowledge. I understand that withholding or giving false information will make my son/daughter ineligible for admission and future enrolment. I further understand that my son/daughter may be required to appear for an interview or to undergo such test as requested by the Scholarship Board of Admission as a condition for admission to the programme of study for which I have applied. Saya, No K/P, waris kepada dengan ini mengaku bahawa saya telah mengisi Borang Permohonan ini dan semua maklumat yang diberikan adalah tepat dan lengkap. Saya sedar dengan memberikan maklumat palsu boleh menyebabkan anak saya tidak dibenarkan untuk mendaftar di masa hadapan. Saya juga memahami bahawa anak saya akan dipanggil untuk sesi temuduga oleh Jawatankuasa Biasiswa sebagai syarat untuk kemasukan ke program yang dipohon. Signature / Tandatangan : Date / Tarikh : PART 5: REFEREES (LOCAL AUTHORITIES E.G: JKKK/KETUA KAMPUNG) BAHAGIAN 5: PENGESAHAN (pihak berkuasa tempatan E.G: JKKK/KETUA KAMPUNG) Name Nama Position Jawatan Organisation Institusi Signature &Stamp Tandatangan & Cop Rasmi Scholarship application for AIIS 4

CHECKLIST / SENARAI SEMAK Please submit all the following items along with the Application Form to ensure that your application is complete and can processed for admission. Please tick ( ) in the appropriate boxes to indicate items that have been attached. Sila serahkan perkara perkara dibawah bersama Borang Permohonan untuk memastikan permohonan anda lengkap bagi proses kemasukan. Sila tandakan ( ) di dalam kotak yang berkenaan sebagai rujukan. 1. Birth Certificate (certified true photocopy) / Sijil Lahir (salinan disahkan) 2. Certificate of completion of early education/kindergarten / Sijil tamat pengajian taska 3. 4 recent passport-size, colour photographs / 4 keping gambar berwarna beukuran passport 4. Financial Statement or Confirmation of parent s income / Penyata Kewangan atau pengesahan pendapatan ibubapa atau penjaga 5. Any other relevant documents / Lain lain dokumen yang berkaitan Important: Please submit only certified photocopies of official documents. Penting : Sila serahkan salinan dokumen yang disahkan sahaja Upon completion, please return this form to: Sila hantar borang yang lengkap ke alamat berikut: Yayasan Albukhary Jalan Tun Abdul Razak, 05200 Alor Setar, Kedah Darul Aman, Malaysia (Attention to: Albukhary Scholarship Programme AIIS) FOR OFFICE USE ONLY: UNTUK KEGUNAAN PEJABAT SAHAJA Date received: Tarikh terima: Reference no.: No. Rujukan: Date of verification: Tarikh pengesahan Scholarship application for AIIS 5