Term 1 February

Intake 2013

Innovation Ambassador Development Programme

Application for Admission
Please complete the application form and submit via email to apply@genovasi.my or
fax +603 8318 0716 on or before 4 January 2013. Please note that all information
provided is strictly confidential.
The Innovation Ambassador Development Programme is a 10-week programme from 4
February 2013 to 21 April 2013. After the completion of the 10-week programme,
qualified participants will have the opportunity to gain practical experience through
placement in Government Ministries, Agencies, GLCs or Corporations.
At this point in time, there is no tuition fee for Malaysians enrolled into the
programme.

Genovasi Malaysia Sdn Bhd

c/o Unit Inovasi Khas
Level 1, Quill Building 3
Jalan Teknokrat 5
63000 Cyberjaya, Malaysia
Tel: +603 8318 0210
Fax: +603 8318 0716

(1011506-D)

www.genovasi.my

PERSONAL INFORMATION

Passport
Picture

Full Name ___________________________________________________

Gender

Male

Female

dd
mm
yyyy Place of Birth ________________________
Birthdate ____/____/____

NRIC/Passport ____________________ Nationality _________________________________

CONTACT INFORMATION
Mailing Address ________________________________________________________________
______________________________________________________________________________
City/Town ______________ Postal Code ______________ State _____________________
Telephone _______________ Mobile _______________ Email _______________________

EDUCATION BACKGROUND
Field(s) of Study _______________________________________________________________
(e.g. Law, Systems Engineering, etc.)

Highest Degree _________________________________ Year of Graduation ______________

(e.g. BSc, MA, PhD)

Currently Studying

Yes

No

Name of University _______________________________

Previous Qualifications (please list all previous university/college degrees)

Degree and Field of Study

Name of University/College

Year of Graduation

_____________________________ ____________________________ _________________

_____________________________ ____________________________ _________________
Languages and Proficiency
Please list languages spoken and indicate proficiency level (native speaker, fluent, good, sufficient, poor)

______________________________________ ______________________________________
______________________________________ ______________________________________

OTHER SKILLS AND INTERESTS

Special Skills
Please list your skills (e.g. mechanical skills, computer skills, software, etc.)

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Memberships
Please list any clubs, academic and/or social associations you are a member of
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______________________________________________________________________________________________________

Honours and Awards

Please name the honours or awards and the supporting organisation
______________________________________________________________________________________________________
______________________________________________________________________________________________________

Motivation
Please describe in a short and plausible manner why you would like to study at Genovasi. What do you personally
expect from Innovation Methodology for your professional future?
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CURRICULUM VITAE
Please include a copy of your curriculum vitae (maximum of 2 pages) as part of the application
form.

T-PROFILE
Looking outside of one's own (academic) box is part of the Innovation Ambassador Development
Programme. Since innovative solutions to complex problems require several disciplines, it is
beneficial for problem solvers to speak different "languages" to ease understanding and allow
for varying points of view. It order for us to attain a better insight not only into your
professional and academic experience, but also your interfacing expertise, inter-disciplinary
skills and projects, we ask you to please complete the T-Profile on the next page.
There is only one rule: The vertical bar must be filled with relevant information about your
academic studies (analytical) and in the horizontal bar, you can map competencies and
activities that transcend or do not relate directly to your field of study (creativity). How and in
what format you do this - as a text, drawing, diagram or photograph is completely up to you.

DECLARATION
I declare that the information provided in the application form is true and correct.

Signature ____________________________________________

Date ________________

T-PROFILE