MERDEKA SCHOLARSHIPS

:: Closing Date : 28 January 2014 ::

Attention to all applicants 1. All applicants must fill all required information in sections marked **. 2. Please fill the forms using UPPER CASE LETTERS. 3. Please attach the following documents: a. A signed personal statement of not more than 1,000 words that includes: - a description of the intended area of study - how this will benefit Malaysia - reasons for wanting to study in Oxford - the personal qualities that make you a worthy recipient of a scholarship b. List of academic qualifications and other awards and honours received. c. Copy of document stating the status of application to the University of Oxford d. Two confidential letters of recommendation from referees who can assess in detail the applicant's academic performance and potential

A. DEGREE TO PURSUE **
(Note: All applicants should apply to the University of Oxford. This Section refers to the candidate's separate application to the University of Oxford)

Choose one : Course Name and Code: Department Name :

Masters

PhD/Dphil

[Insert Your Photo Here]

Status of Application for Admission into the University of Oxford: Application submitted a) to The University of Oxford: b) Status of Application Pending Offered a conditional offer Offered an unconditional offer (dd/mm/yy)

B. PERSONAL PARTICULARS **
Full name IC No (New)

Place of Birth Date of Birth (dd/mm/yy)

Race Religion Permanent address Postcode Town State Country

(If outside Malaysia only)

Mailing address

Postcode Town State

Country
(If outside Malaysia only)

Telephone number

a) Mobile b) Home

Email address
(Use upper or lower case as per actual address)

Marital status

Number of children

C. QUALIFICATIONS ** i - Professional qualification attained

Professional body State Title of professional course Year (From) Parts completed All Part Year (Completed) Highest part completed Country

ii - Master's Degree
Institution / University State Discipline Year (From) CGPA / Grade Year (Completed) Country

iii - Undergraduate / First Degree

Institution / University State Discipline Year (From) CGPA / Grade Year (Completed) Point / Class Country

iv - Diploma
Institution / University State Discipline Year (From) CGPA / Grade Year (Completed) Country

D. VOLUNTARY ACTIVITIES (Attach a full description if necessary) i - Society / Club

No 1 2 3

Society / Club

Position / Role Assumed

Year

ii - Sports / Games
No 1 2 3 Sports / Games Represented Year

iii - Awards / Commendations (Name main awards)

No 1
2 3

Awards / Commendations received

Level

Year

E. EMPLOYMENT (If Relevant)

Please provide details of current / last employment, if any : Are you currently employed ? Current / Last Employer name & address Yes No

Number of years with current/last employer

Position in company Last drawn monthly salary

(RM)

F. REFEREES **
Please give details of the two referees who have written letters of recommendation on your behalf.

Referee 1
Name Address

Position Email address

(Use upper or lower case as per actual address)

Referee 2
Name Address

Position Email address

(Use upper or lower case as per actual address)

F. DECLARATION **
I hereby declare that the particulars provided in this form are true in every respect. I understand that if any of these particulars given by me are found to be untrue, my application will be automatically disqualified.

Name : Date :