Prestasi Application Form 2013

Applicant Name: _________________________________

Field of Training

Program to Extend Scholarships and Training to Achieve Sustainable Impacts Phase II (PRESTASI II) provides

opportunities for Indonesians to earn Master degrees which focus on areas that are relevant to the achievement of USAID/Indonesia and Government of Indonesia development goals. The focus areas are as following:

Economic Growth Education

Economics, Finance, Accounting, Insurance and Fiscal Policy

Education Technology focusing on applying information communication technology (ICT) in teaching methodology in the classroom

Agribusiness, Agricultural Economics and Agricultural Biotechnology Policy Math and Science Education in elementary and high

schools

Public PolicyEducation Management and Administration, with focus on Leadership, Management, Financing and Planning

Democracy and Governance Curriculum and Instruction in Primary Education

Public Affairs

Vocational Education to prepare individuals for leadership positions in secondary, postsecondary, community or technical colleges, higher education, business and industry

Public Administration, with focus on Public Accountability or Administration of Justice Inclusion and Special Education

Public Policy Health

Political Science U.S. university Indonesia university

Public Management, with focus on Public Accounting Maternal child health and reproductive health

Business Administration, with focus on: Organization and Capacity Building, Private Partnership, and Non-profit Management

Health system strengthening: health financing/economics, health management and policy, data information management, and logistic supply chain management

Environment Public Health

Biodiversity Conservation and Natural Resources Management Health promotion and behavior

Sustainable Forest Management, Agro-forestry and Community Forestry Hospital Management

Marine and Coastal Zone Management Nursing Management and Health Care

Clean Energy Biostatistics/Epidemiology

Water and SanitationInfectious Diseases and Vaccinology (for U.S. universities only)

Climate Change – Adaptation and Disaster Risk Reduction (DRR)

Medical laboratory science (for U.S. universities only)

PRESTASI II – Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II 1

Applicant Name: _________________________________

Emerging disease and emerging infectious disease (for U.S. universities only)

Health (continued)

Health/Medical Science and Technology (include: pathology, respiratory, immunology, reproductive biology, clinical medicine, etc.) – for U.S. universities only

Occupational safety and health – for Indonesia universities only

Drug management and policy – for Indonesia universities only

Nutrition and Health – for Indonesia universities only

Environmental Health – for Indonesia universities only

Field epidemiology – for Indonesia universities only

Note: For Applicants who wish to apply for the Health sector, please choose either the U.S. universities or Indonesia universities. Choosing both options is not permitted.


Applicant Name: _________________________________

List of Required Documents

Mandatory Documents

1. Completed and signed application form 1 original and 3 copies

2. Certified Undergraduate Certificate 1 original and 3 copies

3. Certified Undergraduate Academic Transcripts 1 original and 3 copies

4. Recent photographs (4 x 6, B/W or color)4 copies, attach to each copy of application form

5. Recent Curriculum Vitae (in English)4 copies, attach to each package of application form

6. Copy of valid national ID Card (KTP or Passport) 1 copy

7.Valid TOEFL® ITP or TOEFL® IBT or IELTS™ scores result

1 copy

8. Original Reference Letters, in sealed envelopes 3 copies

9. Letter of Approval from the Personnel Office * 1 copy

Supplementary Documents

1. Latest salary slip 1 copy

2. Copy of certificates and awards 1 copy

3.Copy of article, journal, research, or cover page of your publication etc.

1 copy

Important

Do not submit original documents. Application forms and attached documents will not be returned. No mandatory and/or supplementary documents can be delivered separately from the application forms,

except the Reference Letters.

* For Applicant who wishes to apply to study in the U.S, Approval Letter from the Personnel Office must stated that, if chosen as scholarship recipient, applicant will be permitted to join the preparation activity prior to departure and will start the study in accordance with USAID PRESTASI’s schedule.

For Applicant who wishes to apply to study in Indonesia (Health sector only), Approval Letter from the Personnel Office must stated that, if chosen as scholarship recipient, approval letter stating that applicant will be released from tasks while studying.


Applicant Name: _________________________________

To expedite the process, please pay attention to the following instruction below:

Put together all documents and arrange them into 4 separate sets. Each set should contain documents as described above and every set should be in the same order. Please see below example:

Original Form Copy 1 Copy 2 Copy 3(No 1 – 12) (No 1 – 5) (No 1 – 5) (No 1 – 5)

Please do not bind the documents. Please use paper clips to expedite the dividing process.

From where did you first hear about PRESTASI?

□ Newspaper or magazine □ Television

□ Brochure or flyer □ Radio

□ Education Fair or presentation session □ Internet or mailing list

□ Social media (Facebook or Twitter) □ Advertisement at university

□ Other, please specify: _________________________________________

Application Delivery

Application packages should be delivered via post / mail or hand-delivered to IIEF office to the below address:USAID Scholarship PRESTASI ProgramMenara Imperium, 28th Fl. Suite AJl. HR Rasuna Said Kav.1, Kuningan, Jakarta 12980

The application packages should arrive at IIEF office at the latest on April 12, 2013, before 4.30 PM. No documents are allowed to be sent via email or fax. Late or incomplete application will not be considered.

Early application submission is highly encouraged.


Applicant Name: _________________________________

1. PERSONAL INFORMATIONPlease give your personal details exactly as it appear on official documents (National ID, Passport, Birth Certificate, etc.). Each field is mandatory.

First Name:___________________________________________________________

Middle Name:_________________________________________________________

Last Name / Family Name:_______________________________________________

*if you have only one name, please write down your name in the Last Name sectionPlease attach a recent photo

(color or B/W)

4 x 6National ID Details: (please tick only one box below)

□KTP □Passport

No:_________________________________

Expiry Date (DD/MM/YY):_______________

Date of Birth (DD/MM/YY)

Place of Birth

Gender Male □ Female □

Nationality

Address:

*please fill in with your current address

City

Province

Postal Code

Home phone no.*please write down the code area

Mobile no.

Email Marital Status □Single □Married □Widow/widower

Physical Limitation / Impairment:

Yes □ No □If yes, please specify:

2. SPOUSE DETAILS (if applicable)

Name □ Working □ Not Working

Tel. / Mobile Phone Position

Working Institution

Address:

*please fill in only if the spouse’s address is different than yours

City

Province

Postal Code

3. DEPENDANTS DETAILS (if applicable)


Applicant Name: _________________________________

Dependant is a person (s) who rely on you for financial support. For example: child or siblings. Please use additional paper if necessary.

Name Gender Age Relationship

1.

2.

3.

4. PARENT’S INFORMATION

Father’s Details

Name Tel. / Mobile No.

Status □ Alive □DeceasedWorking Status □ Working □ Not Working

Highest Level of Education □None □Primary □Secondary □Diploma □Undergraduate □ Graduate/Postgraduate

Working Institution Position

Home Address:

*please fill in only if it is different than yours

City

Province

Postal Code

Mother’s Details

Name Tel. / Mobile No.

Status □ Alive □DeceasedWorking Status □ Working □ Not Working

Highest Level of Education □None □Primary □Secondary □Diploma □Undergraduate □ Graduate/Postgraduate

Working Institution Position

Home Address:

*please fill in only if it is different than yours

City

Province

Postal Code

Note: Information given for question number 2 – 4 are for statistical purposes only and will have no bearing on your selection as a USAID PRESTASI Participant. All information will be kept strictly confidential by IIEF.


Applicant Name: _________________________________

5. PROPOSED FIELD OF STUDYPlease refer to page 1 and 2 in this Application Form. You are allowed to propose up to 3 choices under the same Field of Training.

Field of Training Area of Study

Briefly describe the reason why you choose the above study. It should not be more than 100 words. Additional paper is not allowed.





6. ENGLISH LANGUAGE PROFICIENCYPlease tick only one box below and attached the copy of certificate. Prediction test is not allowed.

Type of test □TOEFL® ITP □ TOEFL® IBT □ IELTS™ Overall score

Date of test taken(DD/MM/YY)

Test Location


Applicant Name: _________________________________

7. PROPOSED UNIVERSITYIf you have no particular preferences and would like PRESTASI to identify a suitable institution for you, please proceed to the next section.

First Choice of University

Name of University Complete Address:

Faculty / Department

Have you requested admission to the university □Yes □No

Have you received an admission from the university *if yes, please attached the Letter of Admission

□Yes □No

Are you receiving or applying to get funding support □Yes □No

If receiving, please specify the amount

Contact Person Email

Second Choice of University

Name of University Complete Address:

Faculty / Department

Have you requested admission to the university □Yes □No

Have you received an admission from the university *if yes, please attached the Letter of Admission

□Yes □No

Are you receiving or applying to get funding support □Yes □No

If receiving, please specify the amount

Contact Person Email

8. EDUCATIONAL BACKGROUNDList of universities and colleges attended. Please start with the most recent one.

a. Name of Institution

Degree (s) Obtained

City Country

Faculty Major

Start Date (MM/YY)

End Date (MM/YY) GPA


Applicant Name: _________________________________

8. EDUCATIONAL BACKGROUND (continued)List of universities and colleges attended. Please start with the most recent one.

b. Name of Institution

Degree (s) Obtained

City Country

Faculty Major

Start Date (MM/YY)


c. Name of Institution

Degree (s) Obtained

City Country

Faculty Major

Start Date (MM/YY)


d. Name of Institution

Degree (s) Obtained

City Country

Faculty Major

Start Date (MM/YY)


e. Name of Institution

Degree (s) Obtained

City Country

Faculty Major

Start Date (MM/YY)



Applicant Name: _________________________________

9. SCHOLARSHIP HISTORYOnly write down scholarship or fellowship that you received started from university until present. Additional paper is allowed if necessary.

Have you ever received a scholarship or other funding support from any institution? □Yes □No*if no, please proceed to the next section

Scholarship title Level ofEducation

Start date (DD/MM/YY) End Date (DD/MM/YY)

Scholarship Provider

Contact Person(Name & Email)

Funding □Full □Partial Type of scholarship □Degree □Non – degree











10. EMPLOYMENT HISTORY


Applicant Name: _________________________________

List your work experiences since university until present. Start with the most current one. Additional paper is allowed if necessary.

a. Name of Institution

Position Title

Full Address : Start date (MM/YY)

End date (MM/YY)

Monthly salary*if applicable, please enclose the salary slip

Phone

*please write down the code area

Email address

Responsibility: Level of staffing:

□ Low rank

□ Middle rank

□ Top management

□ Not applicable

b. Name of Institution

Position Title

Full Address : Start date (MM / YY)

End date (MM / YY)

Responsibility:

c. Name of Institution

Position Title


End date (MM / YY)

Responsibility:

10. EMPLOYMENT HISTORY (continued)


Applicant Name: _________________________________

d. Name of Institution

Position Title


End date (MM / YY)

Responsibility:

e. Name of Institution

Position Title


End date (MM / YY)

Responsibility:

f. Name of Institution

Position Title


End date (MM / YY)

Responsibility:


Applicant Name: _________________________________

11. COMMUNITY SERVICES ACTIVITIESList professional, societal or other organizations in which you now hold membership or in which you have been active in the past. You are allowed to use additional paper if necessary.

a. Name of institution

Start date (MM/YY) Address:

End date (MM/YY)

Position

Responsibility:

b. Name of institution


End date (MM/YY)

Position

Responsibility:

c. Name of institution


End date (MM/YY)

Position

Responsibility:


Applicant Name: _________________________________

12. LIST OF SIGNIFICANT AWARDS (if applicable)List of significant awards and accomplishments relevant to your application, starting from university level. Please use additional paper, if you need more space. If it is not applicable, please proceed to the next section.

a. Name of award

Year of award Scope of award □ District level □ National level

□ Regional level □ International level

Award provider

b. Name of award



Award provider

c. Name of award



Award provider

d. Name of award



Award provider

e. Name of award



Award provider


Applicant Name: _________________________________

13. LIST OF PUBLICATIONS AND ARTICLES (if applicable)List of publications and articles relevant to your application. Please attach the copy of your articles or the cover page of your publications. You can use additional paper if you need more space. If it is not applicable, please proceed to the next section.

a. Title

Publication date Publisher’s name

Co – writer (if applicable)

b. Title



c. Title



d. Title



14. SHORT ESSAYSPlease note that your answers should not be more than 250 words for each question. Anything over this limit will not be considered. Attach additional paper if necessary.

a. Briefly describe your personal history and daily activities, including interaction with your family members and community.

b. Briefly describe significant factors that have influenced your educational and professional development. What challenges have you overcome in pursuing your professional development? Describe the challenges as well as any insights, perspectives or skills you gained in overcoming them.


Applicant Name: _________________________________

c. What is the topic that you are interested in for your future research? Please elaborate more on the mentioned topic.

d. Briefly describe your professional goals and how they are related to major problems in your country or region.

e. If you are awarded the grant, how will you apply your newly-acquired skills and knowledge to develop your country or region and to improve your performance in your institution?


Applicant Name: _________________________________

f. Illustrate the chain of command in your current institution, which best describe the line of responsibility between you and your supervisor(s), colleagues and/or your subordinate.

g. Please give example(s) on how you demonstrated your leadership skills on your daily activities, whether in your current or previous employment, or within the community.

h. If you are awarded the grant, briefly explain your major concern(s) during your future study and your plan to overcome these concern(s).


Applicant Name: _________________________________

i. Please propose a plan on how will you share your new skills, knowledge and perceptions with your colleagues and community.

j. Briefly describe what you consider to be your strengths and weaknesses


Applicant Name: _________________________________

15. REFERENCE SUMMARYPlease provide the data of your referees. This section should stay attached with the application form.

a. Title and Name

Institution Position

Telephone Email

How long have youknown this referee

Professional relationship to youPlease tick only one box

□ Lecturer or Professor

□ Employer or Job Supervisor

□ Research Advisor

□ Other:______________________

b. Title and Name


Telephone Email






□ Other:______________________

c. Title and Name


Telephone Email






□ Other:______________________


Applicant Name: _________________________________

By my signature below, I certify that, to the best of my knowledge and belief, the information provided in all parts of my application is accurate and complete. I understand that any false statement or the withholding of any relevant information may provide grounds for the withdrawal of any offer of appointment or, if an appointment has been accepted, for its immediate cancellation or termination. If awarded, I agree to comply with any necessary regulations made by the USAID Scholarship PRESTASI Program.

Note:

If sees fit and with your consent, information contains in this application form might be shared to other scholarships program under the USAID Indonesia (please tick Agree). If you decline (please tick Disagree), your information will not be shared to other scholarship program outside USAID PRESTASI and this condition will not affect your selection process under USAID PRESTASI.

□ Agree □ Disagree

Name & Signature of applicant _______________________________________ Date ____________________


Applicant Name: _________________________________

CONFIDENTIAL

LETTER OF REFERENCE

1. Name and the title of Referee :

______________________________________________

2. Referee’s Institution :

______________________________________________

3. How long have you known the applicant? :

______________________________________________

4. In what capacity have you known the applicant?

□ Teacher or Professor □ Employer or Job Supervisor

□ Research Advisor □ Other professional / academic relation (Please Specify):

_____________________________________________

By checking (√) the columns below, please evaluate the applicant compared to the other students or employees you have known during your professional career.

Skills Excellent Good AverageBelow

Average

Leadership □ □ □ □Intellectual ability □ □ □ □Knowledge of the field □ □ □ □Work habits □ □ □ □Motivation to pursue graduate study □ □ □ □Initiative □ □ □ □Adaptability □ □ □ □Emotional maturity □ □ □ □Professional integrity □ □ □ □Social commitment □ □ □ □Problem Solving □ □ □ □

Please circle the number which indicate where the applicant would rank among individuals you have supervised

1 2 3 4


Applicant Name: _________________________________

Poor Excellent


Applicant Name: _________________________________

Q1. Overall, what was your general impression of the applicant?

Q2. How would you describe the applicant’s management style? How does she/he motivate people?

Q3. What are the applicant’s strengths and weakness?

Q4. How would you describe the applicant’s social commitment to his/her community? Please give an example.

Q5. In your opinion, what is the financial need of this applicant?


Applicant Name: _________________________________

Q6. Please give additional facts or comments that may help evaluate the applicant.

Name of Referee: _______________________________________________________________________

Signature: __________________________________Date: _______________________________________

GUIDELINES FOR REFEREE

1. You can use either English or Bahasa Indonesia to fill in this reference letter. The letter can be handwritten

or type if possible.

2. For confidentiality, once the reference letter have been filled in, kindly insert the letter into an envelope, seal

and sign it across the border of the tongue, before handing back the letter to the applicant.

3. Please be informed that the Referee is allowed to post the reference letter directly to IIEF, with below

address:

USAID Scholarship PRESTASI Program

Menara Imperium Lt. 28, Suite A, Jl. HR Rasuna Said Kav.1

Jakarta 12980, Indonesia

4. The Selection Committee should receive the reference letter no later than the deadline: April 12, 2013.

Late submission will not be considered.

5. The reference letter should be submitted in its original form. Submission via fax or email is not permitted.

6. Should the Referee has any queries, please contact: [email protected]


mailto:[email protected]

Applicant Name: _________________________________

CONFIDENTIAL

LETTER OF REFERENCE


______________________________________________


______________________________________________


______________________________________________




_____________________________________________



Average



1 2 3 4


Applicant Name: _________________________________

Poor Excellent


Applicant Name: _________________________________







Applicant Name: _________________________________


Name of Referee: _______________________________________________________________________

Signature: __________________________________Date: _______________________________________







address:










Applicant Name: _________________________________

CONFIDENTIAL

LETTER OF REFERENCE


______________________________________________


______________________________________________


______________________________________________




_____________________________________________



Average



1 2 3 4


Applicant Name: _________________________________

Poor Excellent


Applicant Name: _________________________________







Applicant Name: _________________________________


Name of Referee: _______________________________________________________________________

Signature: __________________________________Date: _______________________________________







address:










Prestasi Application Form 2013

Documents

achieve sustainable

mm yy

applicants

prestasi ii

applicants

professor

workingposition

scholarship