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Preliminary Application Form

Borang Permohonan

Gambar
terbaru

All forms must be HANDWRITTEN clearly in black or blue ink pen and every question must be answered.
Setiap borang hendaklah ditulis dengan jelas sama ada dalam dakwat hitam atau biru sahaja.Sila jawab semua soalan dengan lengkap.

CHECKLIST- SENARAI SEMAK

Check that you have filled ALL the information on this form and include:
Semak semula SETIAP maklumat yang telah diisi dan sertakan perkara-perkara yang berikut:

A RM30 cheque/postal order/money order No._________ made payable to 'Yayasan Antarabudaya Malaysia'
RM30 dalam bentuk cek/wang pos/kiriman wang No. __________ atas nama Yayasan Antarabudaya Malaysia

Your past 2 years school results (Compulsory)

Keputusan peperiksaan terkini bagi 2 tahun lalu (Wajib)

A photocopy of your IC (both sides)

Satu salinan kad pengenalan(kedua-dua belah)

A recent passport photograph of yourself

Gambar ukuran passport yang terbaru.

PERSONAL INFORMATION- MAKLUMAT PERIBADI

Name (as in IC)- Nama (seperti dalam K/P)

IC Number- Nombor Kad Pengenalan

Mr/Ms
Gender- Jantina

House Phone Number- Nombor Telefon Rumah

Email Address- Alamat Emel

Mobile Number- Nombor Telefon Bimbit

Postal Address- Alamat Surat-Menyurat

OTHER INFORMATION- MAKLUMAT LAIN

How did you hear about AFS? - Bagaimanakah anda mengetahui mengenai AFS?
Online
School
Road Show
Internet

Sekolah

Promosi Bergerak

Friends

Newspaper

Others

Kawan

Surat khabar

Lain-lain _________________

My preferred countries are (kindly refer to inset)- Negara-negara pilihan saya ialah (sila rujuk sisipan)
1) _______________
2) _______________
3) _______________
(We cannot guarantee your first choice but we will do our best!)- (Kami tidak memberi sebarang jaminan anda akan mendapat pilihan pertama anda)

About your interest in AFS Program- Minat anda dalam Program AFS
Year Program (8 months or more)
Intensive Program (4-11 weeks)
Program Setahun (8 bulan atau lebih)

Departing in-Bertolak pada

Dec/Jan/Feb/March

Program Intensif (4-11 minggu)

Dis/Jan/Feb/Mac

Semester Program (4-8 months)

Very Short Program (up to 4 weeks)

Jun/Jul/Aug/Sept

Program Semester (4-8 bulan)

Program Pendek (sehingga 4 minggu)

www.afs.org.my

Jun/Jul/Ogos/Sep

Connecting Lives,Sharing Cultures

SCHOOL INFORMATION- MAKLUMAT SEKOLAH

Name of School- Nama Sekolah
School Address- Alamat Sekolah
Telephone Number- Nombor Telefon

Fax Number- Nombor Fax

I am in Form(kindly provide class name)- Saya di tingkatan (sila catitkan nama kelas)
Post held in school(if any)- Jawatan disandang di sekolah (jika ada)

PARENTS/GUARDIAN(S) INFORMATION- MAKLUMAT IBUBAPA/PENJAGA

Father/Stepfather/Guardian Name- Nama Bapa/Bapa Tiri/Penjaga
Employer- Majikan

Occupation-Pekerjaan

Office Number- Nombor Pejabat

Mobile Number-Nombor Telefon Bimbit

Email Address- Alamat Emel

Mother/Stepmother/Guardian Name- Nama Ibu/Ibu Tiri/Penjaga
Employer- Majikan

Occupation-Pekerjaan

Office Number- Nombor Pejabat

Mobile Number-Nombor Telefon Bimbit

Email Address- Alamat Emel

EMERGENCY CONTACT- MAKLUMAT KECEMASAN

If your parents/guardian cannot be reached, please indicate someone in your community whom we can contact:
Jika ibubapa/penjaga tidak dapat dihubungi,sila nyatakan maklumat individu yang boleh dihubungi:
Full Name-Nama Penuh
Relationship-Hubungan

Office Phone-Telefon Pejabat

House Phone-Telephone Rumah

Mobile Number- Telefon Bimbit

HOSTING- PENEMPATAN PELAJAR ASING

Have any of your family members participated on an AFS program?
Adakah sesiapa dari ahli keluarga pernah menyertai program AFS?

No

Yes. Please specify name, country and which year?

Tidak

Ya.Sila nyatakan nama,Negara dan tahun penyertaan.

_________________________________

Are you or any of your family members involved in AFS?

No
Yes. If yes,how?
Tidak

www.afs.org.my

Ya.Jika ya, bagaimana? __________________________________

Connecting Lives,Sharing Cultures

HOSTING- PENEMPATAN PELAJAR PERTUKARAN

Do you know anyone (family,friends,relatives etc) who would like the opportunity to host an AFS student?
With their permission, please provide contact details. Your support of hosting would be appreciated.
Adakah anda mengetahui sesiapa (keluarga,rakan-rakan,saudara-mara dll) yang berminat untuk menjadi keluarga angkat kepada pelajar
pertukaran AFS?
Full Name- Nama Penuh

Phone Number- Nombor Telefon

Email Address- Alamat Emel

PERSONAL STATETMENT- PENGENALAN DIRI

Describe yourself and your personality and what is important to you

Huraikan mengenai diri dan personality anda dan apa yang penting dalam hidup anda.

Detail your participation in school and community activities

Perincikan penyertaan anda di sekolah dan aktiviti-aktiviti kemasyarakatan

What do you hope to gain from AFS program?

Apa yang anda berharap dapat manfaat dari program AFS?

** Your entire personal statement should be between 80-100 words ONLY.

Kenyataan diri anda haruslah di antara 80-100 patah perkataan SAHAJA

www.afs.org.my

Connecting Lives,Sharing Cultures

SCHOLARSHIP APPLICATION- PERMOHONAN BIASISWA

For the list of scholarships available, please refer to the list of scholarship (in the inset)
Untuk senarai biasiswa yang boleh dipohon, sila rujuk senarai biasiswa yang terdapat dalam sisipan

If you wish to apply for an AFS Scholarship, please complete the scholarship section below.
Jika anda ingin memohon untuk biasiswa AFS, sila lengkapkan bahagian biasiswa di bawah.

Please note that, application for scholarship does not automatically guarantee you an AFS Scholarship. Your
application will be reviewed by the AFS Scholarship Selection Committee to determine whether you are eligible to
receive our scholarship. However, you may still participate as a fee paying candidate if you fail to receive one.
Should any information disclosed is found not true; your application will be disqualified.
Adalah dimaklumkan bahawa permohonan ini tidak secara automatik melayakkan anda untuk sebarang biasiswa AFS. Permohonan anda akan dikaji
semula oleh Jawatan Kuasa Pemilihan Biasiswa AFS untuk menentukan sama ada anda layak menerima biasiswa tersebut. Bagaimanapun, anda masih
boleh menyertai program berbayar AFS sekiranya gagal mendapatkan sebarang biasiswa.
Sekiranya didapati sebarang maklumat yang diberi tidak benar, permohonan anda akan terbatal.

I am applying for the following scholarship(s) for which I am eligible for:

Saya layak untuk memohon biasiswa berikut:

Name of Scholarship(s):
Nama Biasiswa

Family Annual Income (Please tick)

Pendapat tahunan keluarga(sila tanda)

Up to RM30,000

RM31,000-RM50,000

RM51,000-RM70,000

Sehingga RM30,000

RM71,000-RM99,000

RM100,000 and above

Lebih dari RM100,000

Number of dependents:
Jumlah tanggungan

I deserve a scholarship because(not more than 30 words)

Saya layak untuk menerima biasiswa kerana(tidak melebihi 30 perkataan)

DECLARATION - AKU JANJI

I HAVE DISCUSSED MY APPLICATION WITH MY FAMILY AND WISH TO APPLY FOR PARTICIPATION IN AN AFS PROGRAM
SAYA TELAH BERBINCANG DENGAN KELUARGA SAYA MENGENAI PERMOHONAN INI DAN INGIN MEMOHON UNTUK MENYERTAI PROGRAM AFS

Applicants Signature / Tandatangan Pemohon

Date/Tarikh:

Parent/Guardians Signature / Tandatangan Ibu/Bapa/Penjaga

Date/Tarikh:

Send this completed application form to:

AFS Malaysia
40A, Jalan SS 22/21, Damansara Jaya,
47400 Petaling Jaya,
Selangor

Hantarkan borang permohonan yang telah dilengkapkan ke:

*Please keep a copy for your own reference

TH

APPLICATION DEADLINE: 30

APRIL 2015

Tarikh tutup permohonan

www.afs.org.my

Connecting Lives,Sharing Cultures

SOUTHERN HEMISPHERE (SH) CYCLE 2016/2017

YEAR PROGRAM (8 MONTHS OR MORE)
DEPART

RETURN

FEE (RM)

Argentina

Feb 16

Jan 17

30,000

FORM
(YR 2015)
5

Brazil

Feb 16

Jan 17

28,000

Chile

Feb 16

Jan 17

27,000

China

Feb 16

Jan 17

23,000

Denmark

Feb 16

Jan 17

28,000

Germany

Feb 16

Jan 17

31,000

Japan

Mar 16

Feb 17

27,000

New Zealand

Feb 16

Jan 17

34,000

South Korea

Feb 16

Jan 17

27,000

Switzerland

Feb 16

Jan 17

32,000

DESTINATION

SEMESTER PROGRAM (4 8 MONTHS)

DEPART

RETURN

Austria

Jan 16

July 16

22,000

FORM
(YR 2015)
5

Brazil

Jan 16

July 16

23,000

France

Jan 16

July 16

22,000

Hungary

Jan 16

July 16

22,000

Italy

Jan 16

July 16

22,000

USA (KL-YES Scholarship)

Jan 16

June 16

*Scholarship

USA (BP Scholarship)

Jan 16

June 16

*Scholarship

DESTINATION

FEE (RM)

NORTHERN HEMISPHERE (NH) CYCLE 2016/2017

YEAR PROGRAM (8 MONTHS OR MORE)
DEPART

RETURN

FEE (RM)

Austria

Sept 16

July 17

27,000

FORM
(YR 2015)
5

Belgium Flanders

Sept 16

July 17

27,000

Bosnia Herzegovina

Sept 16

July 17

23,000

Canada

Sept 16

July 17

48,000

France

Sept 16

July 17

28,000

India

Sept 16

July 17

26,000

Mexico

Sept 16

July 17

27,000

DESTINATION

INTENSIVE PROGRAM (4-11 WEEKS)

DESTINATION

FORM
(YR 2015)
3,4,5

DEPART

RETURN

FEE (RM)

Dec 15

Feb 16

14,000

Finland

Jul 16

Aug 16

15,000

3,5

France*

Dec 15

Feb 16

17,000

3,4,5

Italy (Arts Program)

June 16

Aug 16

17,000

3,5

Italy

Dec 15

Feb 16

17,000

3,4,5

Japan

Dec 15

Jan 16

17,000

3,4,5

Turkey

Dec 15

Feb 16

14,000

3,4,5

China

VERY SHORT PROGRAM (UPTO 4 WEEKS)

DEPART

RETURN

FEE (RM)

Denmark

Jan 16

Feb 16

17,000

FORM
(YR 2015)
3,5

Germany (Green Academy)

Jan 16

Feb 16

16,000

3,5

Spain (Summer Academy)

June 16

July 16

17,000

3,5

DESTINATION

Scholarships
As part of AFS Malaysias commitment to help your dream come true, we offer various scholarships
that you could be eligible for!
Sebahagian dari komitmen kami di Yayasan AFS Antarabudaya Malaysia adalah untuk membantu menjadikan
impian anda kenyataan dengan menawarkan pelbagai biasiswa.
Scholarships available:
Biasiswa-Biasiswa yang ditawarkan:

Yayasan Antarabudaya Malaysia (YABM)

This is a partial scholarship open to all students who wish to go on the Year
Programme. Preferences will be given to those applying for non-English
speaking countries. Terms and conditions apply.

AFS Global Changemakers Scholarship

To commemorate 100 Years celebration, AFS will offer participants to
participate in the AFS Global Changemakers Scholarship Program. This is a
full scholarship open to all students who wish to go on the Year
Programme to Argentina and India. Terms and conditions apply.

Kennedy-Lugar Youth Exchange and Study (YES)

A full scholarship offered to all students aged 17 years / Form 5 who wish to
go to USA on the Semester Programme.

Carl Zeiss Scholarship

A partial scholarship will be offered to children's employee of Carl Zeiss.
The scholars can choose between these destinations as host countries:
Brazil, China, France, Germany, Italy, India, Mexico, Russia, Spain, USA.

British Petroleum (BP)

The BP Scholarship is for a semester of 6 months to the United States of
America fromJanuary - June. You may apply by filling up the column
provided in the Preliminary Application form.

Please note that AFS reserves the right to change the program fee and details without prior notice
AFS Yayasan Antarabudaya Malaysia berhak menukar jumlah yuran serta syarat dan terma tanpa sebarang notis
AFS also reserves the right not to proceed with the program if it is deemed not viable or is cancelled by the host country
AFS juga berhak untuk tidak meneruskan program jika didapati program tersebut tidak sesuai ataupun dibatalkan oleh negara yang menawarkan program tersebut.
The RM 30.00 application fee is not refundable
Yuran permohonan sebanyak RM 30.00 tidak akan dikembalikan
Incomplete applications will be rejected
Permohonan yang tidak lengkap tidak akan diproses.
Short listed candidates will be called for an interview with the Education State Dept in May/June 2015 (interview may be held during school holidays).
Request to change date and venue will not be entertained.
Pelajar yang disenarai-pendekkan akan dipanggil untuk menghadiri temuduga di Jabatan Pelajaran Negeri masing-masing pada bulan Mei/Jun 2014(temuduga
ada kemungkinan dilakukan semasa cuti sekolah).Permohonan untuk menukar tarikh atau tempat temuduga tidak akan dilayan.