'r,~~[t - db.grad.nu.ac.thpornthip/pdf/Scholarship/2012_01_12_ZelandA… · Oepdikbud would cover-a one way ticket froni Jakarta-to the province where the higher education institution
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32 State University of Surabaya NO 6 Bahasa rndonesia - Regular 1 Year Malang Malang - Jawa Tlmur (Indonesian ~ Regular 6Month (UMrMalang Tefp1 Fax (0341) 551312 L8nguege)
Websitewwwmalang8cld
33 Teachrand Sirnpang Arjuno 14 B Regular 1 Year Educational
Institute of Budi Teip (0341) 326019 Language) UtOmoMlln9 (IKIP 323214 -Senl Budl Utomo Fax (0341) 326019 (Art) Malang) Websitlil
wwwJk~budlutomoacld
34 Polytechnic of Jalan Veleran PO BOX 04 Bahasa Indonetia - Regular 1 Year Malang Malang 65145 (Indonesfan - Regular 6 Month (POLINEMA) TelpiFax (0341) 562158 Language)
Website (tIWN poltek-malangacid
35 Malang Ja~n Raya Ttogomas24B Bahasa Inacnesia - Regular 1 Year Muhammadiyah Maiang (IndOnesian - Regular 6 Month University (UMM Telp (0341)46431819 Language)
Faits (0341) 460782 I 460345 Website WWWummacid
36 VoCational Jalan Teluk MaIIdar AljOsari Bahasa Indonesia - Regular 1 Year Education Tromol Pos 5 Malang 65102 (I ndonesian Development TeJp (0341) 491239 Language) Center (P4lK) Website Teknol9il1 Malena httpwwwvedc ma~rtgcom
37 University of Jalan Kalimantan 37 Bahasa Indonesia - Regular 1 Year Jamber Kampus TegarSoto (Indotl8slan - Regular 6 Month (OJ) Language)
T~lp (0331) 337422 F~(0331337422
~ember68121
Email relctorunejecJd Web wwwuneJac1d Kampus IKlP Surabaya Bahasa Indonesia38 Slale University of -Regular 1 Year
Surabaya (Indonesian bull Regular 6 Month (UNESA)
~tintang Language)
Telp (031) 8290357 Surabaya - Jaws Timur
Website httDilwwwunesascld
39 Ainangga Kanpus C Mulyorejo bull Regular 1 Yaar University
SUtorejo No 59 Surabaya Bahasa IndonesiaMuham~dlYllh Telp (031) 3811966 (Indonesian - Regular 6 Month
Surabaya (UNMUH language) Surabaya)
Fax (031) 3813096 WebSite httpwINwacid
I
6
~ 49 Mulawarman Kamp1 Unmul ~Jnung Bahasa Indonesia - Regular 1Year
UnIversity Kelu8 Kotak Pas 1068 (Indonesian bull Regular 6 Month CUNMUL) Samarinda languag~) Kalimantan Timur Telp(0541) 748698
Fax (0541) 747479 WebWWWunmulac1d
50 Makasar SultanmiddotAlaudfn No 259 Bahasa Indonesia bull R~ular 1 Yeai Muhammadlyah MakaSSal (Indonesian - Regular 6 Month UnIVersity Telp (041 1881593 41nguage) (UNISMUH Fax (0411) 865588 Makasal) Web WWWunlsmuhaeid
51 UnlVerty of Jalan Perintis Kemerdekaao Bahasa Indonesia - Regular 1 Year Hasanuddln KM 10 Makasser (Indonesian - Regular 6 Month Makasar (UNHAS) Teip (0411) 584002 588200 Language)
Fax (0411) 58518B Web wwwunhasscid
52 Sam Ratulangi ~Bahaaa Indonesia ~ Regular 1 Year University Manado
KamPUB UntalBshu (IndonesianMenado North Sulawesi bull Regular 6 Month
(UNSRAT) Telp (0431) 863785 863886 language) bull Summer 3 Monthmiddot Fall (0431) a22568 middotPerlkanan amp web wwwunsrataQid Kelautan (Flsherfes
and Marine) - PerUinlan jAgricuHureJ
bull Regular 1Year Komputer
Jt Oipatl Ukur 102 118 bullTeknr~ Komputer53 Universitas (Computer
Indonasla Bandung4Q132
Technology) (UNIKOIiI) Bandung
Tep (022) 250 3J)54 bull Sistemlnfonnasi
Webwwwunlkornscid Fax (022) 253 3754
(Information System) bull Akunlansl
I(Accounting)
Bureau of Planning and Il)femationalCooperation Ministry of Educatlonand Culture
APPUCATION FORM SCHOLARS8IP FORDARMASISWA RI PROGRAMmiddot
INSTRUCTIONS
Please answer each questions clearly and completely Type or print in ink Read carefully and follow all directions Ifyou more spac~ attaoh additional pages of the same size Submit the completed fonn duly signed in lhroo copies to the Indonesian EmbassyIDipJomaticRef)resentative in your country
A PERSONAL DETAILS
I a Family name
b First name
2 Date of birth affix photo here
J Plllce ofhirth 4x6cm
4 MalclFemale
5 Nationality
6 Religion
7 Paspor Number Validity of
8 E-maH
9 a Mariml status 0 Single a Married b Do you have a husbandiwife or any dependan~
(Please give details ofnaine relationship and date of birth)
NO NAME RELATIONSHIP AGE
I
------ --- ------ ----- ------- - -- ~--
bull
D PROPOSED PROGRAM AND FlELD OF STIJDV (to be answered as detailed as possible)
I Program aD Regular I Year
bD Summer 6 Month
c 0 Regular) Month
Frst Chpice
Place ofStudy
Subject ofStudy
SecondCholu
Place ofStudy
Subject ofStudy
2 Outline your proposed field ofSludy and indicate the pracdcal use to be made of this study Ifyou are acquainted with the possibilities ofstudy offered in Indonesia iisntle institutes or projects you propose to study or the specific course you wish to attend
(Additional pa~lerfor mnre information)
)
--------~-~--~
List any siggificant publication you have written (do not attach)
l-ave you applied for any other scholarship DYes o No
It ~ 6 I ~ ~~VlUIJ1Jn1flLUu~~alL)ft1 Gl LVlflU 1)1JVIJLUVLft~~ u~~n1middotm1~nDtJ2J )1U1U Coo L~flqJai VI I ltII I tI I ttlmiddot v bull If vn~~~1JHnoUl~anlU1Jq1JU11UI ~~LVlfIJ8~U UiIfl1L~JVI~L LiI12Jn1SOU~1J~n~LJl1SJm
tI~1Ul~nft1Jriouiu~~lfll~n1~ ~aut )a11J1 if ~11t1f1~ ~nfJ ~lfl Hfi1 [1 pound11 un ~ ~o na1~n1HIijfI 1~vI
32 State University of Surabaya NO 6 Bahasa rndonesia - Regular 1 Year Malang Malang - Jawa Tlmur (Indonesian ~ Regular 6Month (UMrMalang Tefp1 Fax (0341) 551312 L8nguege)
Websitewwwmalang8cld
33 Teachrand Sirnpang Arjuno 14 B Regular 1 Year Educational
Institute of Budi Teip (0341) 326019 Language) UtOmoMlln9 (IKIP 323214 -Senl Budl Utomo Fax (0341) 326019 (Art) Malang) Websitlil
wwwJk~budlutomoacld
34 Polytechnic of Jalan Veleran PO BOX 04 Bahasa Indonetia - Regular 1 Year Malang Malang 65145 (Indonesfan - Regular 6 Month (POLINEMA) TelpiFax (0341) 562158 Language)
Website (tIWN poltek-malangacid
35 Malang Ja~n Raya Ttogomas24B Bahasa Inacnesia - Regular 1 Year Muhammadiyah Maiang (IndOnesian - Regular 6 Month University (UMM Telp (0341)46431819 Language)
Faits (0341) 460782 I 460345 Website WWWummacid
36 VoCational Jalan Teluk MaIIdar AljOsari Bahasa Indonesia - Regular 1 Year Education Tromol Pos 5 Malang 65102 (I ndonesian Development TeJp (0341) 491239 Language) Center (P4lK) Website Teknol9il1 Malena httpwwwvedc ma~rtgcom
37 University of Jalan Kalimantan 37 Bahasa Indonesia - Regular 1 Year Jamber Kampus TegarSoto (Indotl8slan - Regular 6 Month (OJ) Language)
T~lp (0331) 337422 F~(0331337422
~ember68121
Email relctorunejecJd Web wwwuneJac1d Kampus IKlP Surabaya Bahasa Indonesia38 Slale University of -Regular 1 Year
Surabaya (Indonesian bull Regular 6 Month (UNESA)
~tintang Language)
Telp (031) 8290357 Surabaya - Jaws Timur
Website httDilwwwunesascld
39 Ainangga Kanpus C Mulyorejo bull Regular 1 Yaar University
SUtorejo No 59 Surabaya Bahasa IndonesiaMuham~dlYllh Telp (031) 3811966 (Indonesian - Regular 6 Month
Surabaya (UNMUH language) Surabaya)
Fax (031) 3813096 WebSite httpwINwacid
I
6
~ 49 Mulawarman Kamp1 Unmul ~Jnung Bahasa Indonesia - Regular 1Year
UnIversity Kelu8 Kotak Pas 1068 (Indonesian bull Regular 6 Month CUNMUL) Samarinda languag~) Kalimantan Timur Telp(0541) 748698
Fax (0541) 747479 WebWWWunmulac1d
50 Makasar SultanmiddotAlaudfn No 259 Bahasa Indonesia bull R~ular 1 Yeai Muhammadlyah MakaSSal (Indonesian - Regular 6 Month UnIVersity Telp (041 1881593 41nguage) (UNISMUH Fax (0411) 865588 Makasal) Web WWWunlsmuhaeid
51 UnlVerty of Jalan Perintis Kemerdekaao Bahasa Indonesia - Regular 1 Year Hasanuddln KM 10 Makasser (Indonesian - Regular 6 Month Makasar (UNHAS) Teip (0411) 584002 588200 Language)
Fax (0411) 58518B Web wwwunhasscid
52 Sam Ratulangi ~Bahaaa Indonesia ~ Regular 1 Year University Manado
KamPUB UntalBshu (IndonesianMenado North Sulawesi bull Regular 6 Month
(UNSRAT) Telp (0431) 863785 863886 language) bull Summer 3 Monthmiddot Fall (0431) a22568 middotPerlkanan amp web wwwunsrataQid Kelautan (Flsherfes
and Marine) - PerUinlan jAgricuHureJ
bull Regular 1Year Komputer
Jt Oipatl Ukur 102 118 bullTeknr~ Komputer53 Universitas (Computer
Indonasla Bandung4Q132
Technology) (UNIKOIiI) Bandung
Tep (022) 250 3J)54 bull Sistemlnfonnasi
Webwwwunlkornscid Fax (022) 253 3754
(Information System) bull Akunlansl
I(Accounting)
Bureau of Planning and Il)femationalCooperation Ministry of Educatlonand Culture
APPUCATION FORM SCHOLARS8IP FORDARMASISWA RI PROGRAMmiddot
INSTRUCTIONS
Please answer each questions clearly and completely Type or print in ink Read carefully and follow all directions Ifyou more spac~ attaoh additional pages of the same size Submit the completed fonn duly signed in lhroo copies to the Indonesian EmbassyIDipJomaticRef)resentative in your country
A PERSONAL DETAILS
I a Family name
b First name
2 Date of birth affix photo here
J Plllce ofhirth 4x6cm
4 MalclFemale
5 Nationality
6 Religion
7 Paspor Number Validity of
8 E-maH
9 a Mariml status 0 Single a Married b Do you have a husbandiwife or any dependan~
(Please give details ofnaine relationship and date of birth)
NO NAME RELATIONSHIP AGE
I
------ --- ------ ----- ------- - -- ~--
bull
D PROPOSED PROGRAM AND FlELD OF STIJDV (to be answered as detailed as possible)
I Program aD Regular I Year
bD Summer 6 Month
c 0 Regular) Month
Frst Chpice
Place ofStudy
Subject ofStudy
SecondCholu
Place ofStudy
Subject ofStudy
2 Outline your proposed field ofSludy and indicate the pracdcal use to be made of this study Ifyou are acquainted with the possibilities ofstudy offered in Indonesia iisntle institutes or projects you propose to study or the specific course you wish to attend
(Additional pa~lerfor mnre information)
)
--------~-~--~
List any siggificant publication you have written (do not attach)
l-ave you applied for any other scholarship DYes o No
32 State University of Surabaya NO 6 Bahasa rndonesia - Regular 1 Year Malang Malang - Jawa Tlmur (Indonesian ~ Regular 6Month (UMrMalang Tefp1 Fax (0341) 551312 L8nguege)
Websitewwwmalang8cld
33 Teachrand Sirnpang Arjuno 14 B Regular 1 Year Educational
Institute of Budi Teip (0341) 326019 Language) UtOmoMlln9 (IKIP 323214 -Senl Budl Utomo Fax (0341) 326019 (Art) Malang) Websitlil
wwwJk~budlutomoacld
34 Polytechnic of Jalan Veleran PO BOX 04 Bahasa Indonetia - Regular 1 Year Malang Malang 65145 (Indonesfan - Regular 6 Month (POLINEMA) TelpiFax (0341) 562158 Language)
Website (tIWN poltek-malangacid
35 Malang Ja~n Raya Ttogomas24B Bahasa Inacnesia - Regular 1 Year Muhammadiyah Maiang (IndOnesian - Regular 6 Month University (UMM Telp (0341)46431819 Language)
Faits (0341) 460782 I 460345 Website WWWummacid
36 VoCational Jalan Teluk MaIIdar AljOsari Bahasa Indonesia - Regular 1 Year Education Tromol Pos 5 Malang 65102 (I ndonesian Development TeJp (0341) 491239 Language) Center (P4lK) Website Teknol9il1 Malena httpwwwvedc ma~rtgcom
37 University of Jalan Kalimantan 37 Bahasa Indonesia - Regular 1 Year Jamber Kampus TegarSoto (Indotl8slan - Regular 6 Month (OJ) Language)
T~lp (0331) 337422 F~(0331337422
~ember68121
Email relctorunejecJd Web wwwuneJac1d Kampus IKlP Surabaya Bahasa Indonesia38 Slale University of -Regular 1 Year
Surabaya (Indonesian bull Regular 6 Month (UNESA)
~tintang Language)
Telp (031) 8290357 Surabaya - Jaws Timur
Website httDilwwwunesascld
39 Ainangga Kanpus C Mulyorejo bull Regular 1 Yaar University
SUtorejo No 59 Surabaya Bahasa IndonesiaMuham~dlYllh Telp (031) 3811966 (Indonesian - Regular 6 Month
Surabaya (UNMUH language) Surabaya)
Fax (031) 3813096 WebSite httpwINwacid
I
6
~ 49 Mulawarman Kamp1 Unmul ~Jnung Bahasa Indonesia - Regular 1Year
UnIversity Kelu8 Kotak Pas 1068 (Indonesian bull Regular 6 Month CUNMUL) Samarinda languag~) Kalimantan Timur Telp(0541) 748698
Fax (0541) 747479 WebWWWunmulac1d
50 Makasar SultanmiddotAlaudfn No 259 Bahasa Indonesia bull R~ular 1 Yeai Muhammadlyah MakaSSal (Indonesian - Regular 6 Month UnIVersity Telp (041 1881593 41nguage) (UNISMUH Fax (0411) 865588 Makasal) Web WWWunlsmuhaeid
51 UnlVerty of Jalan Perintis Kemerdekaao Bahasa Indonesia - Regular 1 Year Hasanuddln KM 10 Makasser (Indonesian - Regular 6 Month Makasar (UNHAS) Teip (0411) 584002 588200 Language)
Fax (0411) 58518B Web wwwunhasscid
52 Sam Ratulangi ~Bahaaa Indonesia ~ Regular 1 Year University Manado
KamPUB UntalBshu (IndonesianMenado North Sulawesi bull Regular 6 Month
(UNSRAT) Telp (0431) 863785 863886 language) bull Summer 3 Monthmiddot Fall (0431) a22568 middotPerlkanan amp web wwwunsrataQid Kelautan (Flsherfes
and Marine) - PerUinlan jAgricuHureJ
bull Regular 1Year Komputer
Jt Oipatl Ukur 102 118 bullTeknr~ Komputer53 Universitas (Computer
Indonasla Bandung4Q132
Technology) (UNIKOIiI) Bandung
Tep (022) 250 3J)54 bull Sistemlnfonnasi
Webwwwunlkornscid Fax (022) 253 3754
(Information System) bull Akunlansl
I(Accounting)
Bureau of Planning and Il)femationalCooperation Ministry of Educatlonand Culture
APPUCATION FORM SCHOLARS8IP FORDARMASISWA RI PROGRAMmiddot
INSTRUCTIONS
Please answer each questions clearly and completely Type or print in ink Read carefully and follow all directions Ifyou more spac~ attaoh additional pages of the same size Submit the completed fonn duly signed in lhroo copies to the Indonesian EmbassyIDipJomaticRef)resentative in your country
A PERSONAL DETAILS
I a Family name
b First name
2 Date of birth affix photo here
J Plllce ofhirth 4x6cm
4 MalclFemale
5 Nationality
6 Religion
7 Paspor Number Validity of
8 E-maH
9 a Mariml status 0 Single a Married b Do you have a husbandiwife or any dependan~
(Please give details ofnaine relationship and date of birth)
NO NAME RELATIONSHIP AGE
I
------ --- ------ ----- ------- - -- ~--
bull
D PROPOSED PROGRAM AND FlELD OF STIJDV (to be answered as detailed as possible)
I Program aD Regular I Year
bD Summer 6 Month
c 0 Regular) Month
Frst Chpice
Place ofStudy
Subject ofStudy
SecondCholu
Place ofStudy
Subject ofStudy
2 Outline your proposed field ofSludy and indicate the pracdcal use to be made of this study Ifyou are acquainted with the possibilities ofstudy offered in Indonesia iisntle institutes or projects you propose to study or the specific course you wish to attend
(Additional pa~lerfor mnre information)
)
--------~-~--~
List any siggificant publication you have written (do not attach)
l-ave you applied for any other scholarship DYes o No
32 State University of Surabaya NO 6 Bahasa rndonesia - Regular 1 Year Malang Malang - Jawa Tlmur (Indonesian ~ Regular 6Month (UMrMalang Tefp1 Fax (0341) 551312 L8nguege)
Websitewwwmalang8cld
33 Teachrand Sirnpang Arjuno 14 B Regular 1 Year Educational
Institute of Budi Teip (0341) 326019 Language) UtOmoMlln9 (IKIP 323214 -Senl Budl Utomo Fax (0341) 326019 (Art) Malang) Websitlil
wwwJk~budlutomoacld
34 Polytechnic of Jalan Veleran PO BOX 04 Bahasa Indonetia - Regular 1 Year Malang Malang 65145 (Indonesfan - Regular 6 Month (POLINEMA) TelpiFax (0341) 562158 Language)
Website (tIWN poltek-malangacid
35 Malang Ja~n Raya Ttogomas24B Bahasa Inacnesia - Regular 1 Year Muhammadiyah Maiang (IndOnesian - Regular 6 Month University (UMM Telp (0341)46431819 Language)
Faits (0341) 460782 I 460345 Website WWWummacid
36 VoCational Jalan Teluk MaIIdar AljOsari Bahasa Indonesia - Regular 1 Year Education Tromol Pos 5 Malang 65102 (I ndonesian Development TeJp (0341) 491239 Language) Center (P4lK) Website Teknol9il1 Malena httpwwwvedc ma~rtgcom
37 University of Jalan Kalimantan 37 Bahasa Indonesia - Regular 1 Year Jamber Kampus TegarSoto (Indotl8slan - Regular 6 Month (OJ) Language)
T~lp (0331) 337422 F~(0331337422
~ember68121
Email relctorunejecJd Web wwwuneJac1d Kampus IKlP Surabaya Bahasa Indonesia38 Slale University of -Regular 1 Year
Surabaya (Indonesian bull Regular 6 Month (UNESA)
~tintang Language)
Telp (031) 8290357 Surabaya - Jaws Timur
Website httDilwwwunesascld
39 Ainangga Kanpus C Mulyorejo bull Regular 1 Yaar University
SUtorejo No 59 Surabaya Bahasa IndonesiaMuham~dlYllh Telp (031) 3811966 (Indonesian - Regular 6 Month
Surabaya (UNMUH language) Surabaya)
Fax (031) 3813096 WebSite httpwINwacid
I
6
~ 49 Mulawarman Kamp1 Unmul ~Jnung Bahasa Indonesia - Regular 1Year
UnIversity Kelu8 Kotak Pas 1068 (Indonesian bull Regular 6 Month CUNMUL) Samarinda languag~) Kalimantan Timur Telp(0541) 748698
Fax (0541) 747479 WebWWWunmulac1d
50 Makasar SultanmiddotAlaudfn No 259 Bahasa Indonesia bull R~ular 1 Yeai Muhammadlyah MakaSSal (Indonesian - Regular 6 Month UnIVersity Telp (041 1881593 41nguage) (UNISMUH Fax (0411) 865588 Makasal) Web WWWunlsmuhaeid
51 UnlVerty of Jalan Perintis Kemerdekaao Bahasa Indonesia - Regular 1 Year Hasanuddln KM 10 Makasser (Indonesian - Regular 6 Month Makasar (UNHAS) Teip (0411) 584002 588200 Language)
Fax (0411) 58518B Web wwwunhasscid
52 Sam Ratulangi ~Bahaaa Indonesia ~ Regular 1 Year University Manado
KamPUB UntalBshu (IndonesianMenado North Sulawesi bull Regular 6 Month
(UNSRAT) Telp (0431) 863785 863886 language) bull Summer 3 Monthmiddot Fall (0431) a22568 middotPerlkanan amp web wwwunsrataQid Kelautan (Flsherfes
and Marine) - PerUinlan jAgricuHureJ
bull Regular 1Year Komputer
Jt Oipatl Ukur 102 118 bullTeknr~ Komputer53 Universitas (Computer
Indonasla Bandung4Q132
Technology) (UNIKOIiI) Bandung
Tep (022) 250 3J)54 bull Sistemlnfonnasi
Webwwwunlkornscid Fax (022) 253 3754
(Information System) bull Akunlansl
I(Accounting)
Bureau of Planning and Il)femationalCooperation Ministry of Educatlonand Culture
APPUCATION FORM SCHOLARS8IP FORDARMASISWA RI PROGRAMmiddot
INSTRUCTIONS
Please answer each questions clearly and completely Type or print in ink Read carefully and follow all directions Ifyou more spac~ attaoh additional pages of the same size Submit the completed fonn duly signed in lhroo copies to the Indonesian EmbassyIDipJomaticRef)resentative in your country
A PERSONAL DETAILS
I a Family name
b First name
2 Date of birth affix photo here
J Plllce ofhirth 4x6cm
4 MalclFemale
5 Nationality
6 Religion
7 Paspor Number Validity of
8 E-maH
9 a Mariml status 0 Single a Married b Do you have a husbandiwife or any dependan~
(Please give details ofnaine relationship and date of birth)
NO NAME RELATIONSHIP AGE
I
------ --- ------ ----- ------- - -- ~--
bull
D PROPOSED PROGRAM AND FlELD OF STIJDV (to be answered as detailed as possible)
I Program aD Regular I Year
bD Summer 6 Month
c 0 Regular) Month
Frst Chpice
Place ofStudy
Subject ofStudy
SecondCholu
Place ofStudy
Subject ofStudy
2 Outline your proposed field ofSludy and indicate the pracdcal use to be made of this study Ifyou are acquainted with the possibilities ofstudy offered in Indonesia iisntle institutes or projects you propose to study or the specific course you wish to attend
(Additional pa~lerfor mnre information)
)
--------~-~--~
List any siggificant publication you have written (do not attach)
l-ave you applied for any other scholarship DYes o No
32 State University of Surabaya NO 6 Bahasa rndonesia - Regular 1 Year Malang Malang - Jawa Tlmur (Indonesian ~ Regular 6Month (UMrMalang Tefp1 Fax (0341) 551312 L8nguege)
Websitewwwmalang8cld
33 Teachrand Sirnpang Arjuno 14 B Regular 1 Year Educational
Institute of Budi Teip (0341) 326019 Language) UtOmoMlln9 (IKIP 323214 -Senl Budl Utomo Fax (0341) 326019 (Art) Malang) Websitlil
wwwJk~budlutomoacld
34 Polytechnic of Jalan Veleran PO BOX 04 Bahasa Indonetia - Regular 1 Year Malang Malang 65145 (Indonesfan - Regular 6 Month (POLINEMA) TelpiFax (0341) 562158 Language)
Website (tIWN poltek-malangacid
35 Malang Ja~n Raya Ttogomas24B Bahasa Inacnesia - Regular 1 Year Muhammadiyah Maiang (IndOnesian - Regular 6 Month University (UMM Telp (0341)46431819 Language)
Faits (0341) 460782 I 460345 Website WWWummacid
36 VoCational Jalan Teluk MaIIdar AljOsari Bahasa Indonesia - Regular 1 Year Education Tromol Pos 5 Malang 65102 (I ndonesian Development TeJp (0341) 491239 Language) Center (P4lK) Website Teknol9il1 Malena httpwwwvedc ma~rtgcom
37 University of Jalan Kalimantan 37 Bahasa Indonesia - Regular 1 Year Jamber Kampus TegarSoto (Indotl8slan - Regular 6 Month (OJ) Language)
T~lp (0331) 337422 F~(0331337422
~ember68121
Email relctorunejecJd Web wwwuneJac1d Kampus IKlP Surabaya Bahasa Indonesia38 Slale University of -Regular 1 Year
Surabaya (Indonesian bull Regular 6 Month (UNESA)
~tintang Language)
Telp (031) 8290357 Surabaya - Jaws Timur
Website httDilwwwunesascld
39 Ainangga Kanpus C Mulyorejo bull Regular 1 Yaar University
SUtorejo No 59 Surabaya Bahasa IndonesiaMuham~dlYllh Telp (031) 3811966 (Indonesian - Regular 6 Month
Surabaya (UNMUH language) Surabaya)
Fax (031) 3813096 WebSite httpwINwacid
I
6
~ 49 Mulawarman Kamp1 Unmul ~Jnung Bahasa Indonesia - Regular 1Year
UnIversity Kelu8 Kotak Pas 1068 (Indonesian bull Regular 6 Month CUNMUL) Samarinda languag~) Kalimantan Timur Telp(0541) 748698
Fax (0541) 747479 WebWWWunmulac1d
50 Makasar SultanmiddotAlaudfn No 259 Bahasa Indonesia bull R~ular 1 Yeai Muhammadlyah MakaSSal (Indonesian - Regular 6 Month UnIVersity Telp (041 1881593 41nguage) (UNISMUH Fax (0411) 865588 Makasal) Web WWWunlsmuhaeid
51 UnlVerty of Jalan Perintis Kemerdekaao Bahasa Indonesia - Regular 1 Year Hasanuddln KM 10 Makasser (Indonesian - Regular 6 Month Makasar (UNHAS) Teip (0411) 584002 588200 Language)
Fax (0411) 58518B Web wwwunhasscid
52 Sam Ratulangi ~Bahaaa Indonesia ~ Regular 1 Year University Manado
KamPUB UntalBshu (IndonesianMenado North Sulawesi bull Regular 6 Month
(UNSRAT) Telp (0431) 863785 863886 language) bull Summer 3 Monthmiddot Fall (0431) a22568 middotPerlkanan amp web wwwunsrataQid Kelautan (Flsherfes
and Marine) - PerUinlan jAgricuHureJ
bull Regular 1Year Komputer
Jt Oipatl Ukur 102 118 bullTeknr~ Komputer53 Universitas (Computer
Indonasla Bandung4Q132
Technology) (UNIKOIiI) Bandung
Tep (022) 250 3J)54 bull Sistemlnfonnasi
Webwwwunlkornscid Fax (022) 253 3754
(Information System) bull Akunlansl
I(Accounting)
Bureau of Planning and Il)femationalCooperation Ministry of Educatlonand Culture
APPUCATION FORM SCHOLARS8IP FORDARMASISWA RI PROGRAMmiddot
INSTRUCTIONS
Please answer each questions clearly and completely Type or print in ink Read carefully and follow all directions Ifyou more spac~ attaoh additional pages of the same size Submit the completed fonn duly signed in lhroo copies to the Indonesian EmbassyIDipJomaticRef)resentative in your country
A PERSONAL DETAILS
I a Family name
b First name
2 Date of birth affix photo here
J Plllce ofhirth 4x6cm
4 MalclFemale
5 Nationality
6 Religion
7 Paspor Number Validity of
8 E-maH
9 a Mariml status 0 Single a Married b Do you have a husbandiwife or any dependan~
(Please give details ofnaine relationship and date of birth)
NO NAME RELATIONSHIP AGE
I
------ --- ------ ----- ------- - -- ~--
bull
D PROPOSED PROGRAM AND FlELD OF STIJDV (to be answered as detailed as possible)
I Program aD Regular I Year
bD Summer 6 Month
c 0 Regular) Month
Frst Chpice
Place ofStudy
Subject ofStudy
SecondCholu
Place ofStudy
Subject ofStudy
2 Outline your proposed field ofSludy and indicate the pracdcal use to be made of this study Ifyou are acquainted with the possibilities ofstudy offered in Indonesia iisntle institutes or projects you propose to study or the specific course you wish to attend
(Additional pa~lerfor mnre information)
)
--------~-~--~
List any siggificant publication you have written (do not attach)
l-ave you applied for any other scholarship DYes o No
32 State University of Surabaya NO 6 Bahasa rndonesia - Regular 1 Year Malang Malang - Jawa Tlmur (Indonesian ~ Regular 6Month (UMrMalang Tefp1 Fax (0341) 551312 L8nguege)
Websitewwwmalang8cld
33 Teachrand Sirnpang Arjuno 14 B Regular 1 Year Educational
Institute of Budi Teip (0341) 326019 Language) UtOmoMlln9 (IKIP 323214 -Senl Budl Utomo Fax (0341) 326019 (Art) Malang) Websitlil
wwwJk~budlutomoacld
34 Polytechnic of Jalan Veleran PO BOX 04 Bahasa Indonetia - Regular 1 Year Malang Malang 65145 (Indonesfan - Regular 6 Month (POLINEMA) TelpiFax (0341) 562158 Language)
Website (tIWN poltek-malangacid
35 Malang Ja~n Raya Ttogomas24B Bahasa Inacnesia - Regular 1 Year Muhammadiyah Maiang (IndOnesian - Regular 6 Month University (UMM Telp (0341)46431819 Language)
Faits (0341) 460782 I 460345 Website WWWummacid
36 VoCational Jalan Teluk MaIIdar AljOsari Bahasa Indonesia - Regular 1 Year Education Tromol Pos 5 Malang 65102 (I ndonesian Development TeJp (0341) 491239 Language) Center (P4lK) Website Teknol9il1 Malena httpwwwvedc ma~rtgcom
37 University of Jalan Kalimantan 37 Bahasa Indonesia - Regular 1 Year Jamber Kampus TegarSoto (Indotl8slan - Regular 6 Month (OJ) Language)
T~lp (0331) 337422 F~(0331337422
~ember68121
Email relctorunejecJd Web wwwuneJac1d Kampus IKlP Surabaya Bahasa Indonesia38 Slale University of -Regular 1 Year
Surabaya (Indonesian bull Regular 6 Month (UNESA)
~tintang Language)
Telp (031) 8290357 Surabaya - Jaws Timur
Website httDilwwwunesascld
39 Ainangga Kanpus C Mulyorejo bull Regular 1 Yaar University
SUtorejo No 59 Surabaya Bahasa IndonesiaMuham~dlYllh Telp (031) 3811966 (Indonesian - Regular 6 Month
Surabaya (UNMUH language) Surabaya)
Fax (031) 3813096 WebSite httpwINwacid
I
6
~ 49 Mulawarman Kamp1 Unmul ~Jnung Bahasa Indonesia - Regular 1Year
UnIversity Kelu8 Kotak Pas 1068 (Indonesian bull Regular 6 Month CUNMUL) Samarinda languag~) Kalimantan Timur Telp(0541) 748698
Fax (0541) 747479 WebWWWunmulac1d
50 Makasar SultanmiddotAlaudfn No 259 Bahasa Indonesia bull R~ular 1 Yeai Muhammadlyah MakaSSal (Indonesian - Regular 6 Month UnIVersity Telp (041 1881593 41nguage) (UNISMUH Fax (0411) 865588 Makasal) Web WWWunlsmuhaeid
51 UnlVerty of Jalan Perintis Kemerdekaao Bahasa Indonesia - Regular 1 Year Hasanuddln KM 10 Makasser (Indonesian - Regular 6 Month Makasar (UNHAS) Teip (0411) 584002 588200 Language)
Fax (0411) 58518B Web wwwunhasscid
52 Sam Ratulangi ~Bahaaa Indonesia ~ Regular 1 Year University Manado
KamPUB UntalBshu (IndonesianMenado North Sulawesi bull Regular 6 Month
(UNSRAT) Telp (0431) 863785 863886 language) bull Summer 3 Monthmiddot Fall (0431) a22568 middotPerlkanan amp web wwwunsrataQid Kelautan (Flsherfes
and Marine) - PerUinlan jAgricuHureJ
bull Regular 1Year Komputer
Jt Oipatl Ukur 102 118 bullTeknr~ Komputer53 Universitas (Computer
Indonasla Bandung4Q132
Technology) (UNIKOIiI) Bandung
Tep (022) 250 3J)54 bull Sistemlnfonnasi
Webwwwunlkornscid Fax (022) 253 3754
(Information System) bull Akunlansl
I(Accounting)
Bureau of Planning and Il)femationalCooperation Ministry of Educatlonand Culture
APPUCATION FORM SCHOLARS8IP FORDARMASISWA RI PROGRAMmiddot
INSTRUCTIONS
Please answer each questions clearly and completely Type or print in ink Read carefully and follow all directions Ifyou more spac~ attaoh additional pages of the same size Submit the completed fonn duly signed in lhroo copies to the Indonesian EmbassyIDipJomaticRef)resentative in your country
A PERSONAL DETAILS
I a Family name
b First name
2 Date of birth affix photo here
J Plllce ofhirth 4x6cm
4 MalclFemale
5 Nationality
6 Religion
7 Paspor Number Validity of
8 E-maH
9 a Mariml status 0 Single a Married b Do you have a husbandiwife or any dependan~
(Please give details ofnaine relationship and date of birth)
NO NAME RELATIONSHIP AGE
I
------ --- ------ ----- ------- - -- ~--
bull
D PROPOSED PROGRAM AND FlELD OF STIJDV (to be answered as detailed as possible)
I Program aD Regular I Year
bD Summer 6 Month
c 0 Regular) Month
Frst Chpice
Place ofStudy
Subject ofStudy
SecondCholu
Place ofStudy
Subject ofStudy
2 Outline your proposed field ofSludy and indicate the pracdcal use to be made of this study Ifyou are acquainted with the possibilities ofstudy offered in Indonesia iisntle institutes or projects you propose to study or the specific course you wish to attend
(Additional pa~lerfor mnre information)
)
--------~-~--~
List any siggificant publication you have written (do not attach)
l-ave you applied for any other scholarship DYes o No
32 State University of Surabaya NO 6 Bahasa rndonesia - Regular 1 Year Malang Malang - Jawa Tlmur (Indonesian ~ Regular 6Month (UMrMalang Tefp1 Fax (0341) 551312 L8nguege)
Websitewwwmalang8cld
33 Teachrand Sirnpang Arjuno 14 B Regular 1 Year Educational
Institute of Budi Teip (0341) 326019 Language) UtOmoMlln9 (IKIP 323214 -Senl Budl Utomo Fax (0341) 326019 (Art) Malang) Websitlil
wwwJk~budlutomoacld
34 Polytechnic of Jalan Veleran PO BOX 04 Bahasa Indonetia - Regular 1 Year Malang Malang 65145 (Indonesfan - Regular 6 Month (POLINEMA) TelpiFax (0341) 562158 Language)
Website (tIWN poltek-malangacid
35 Malang Ja~n Raya Ttogomas24B Bahasa Inacnesia - Regular 1 Year Muhammadiyah Maiang (IndOnesian - Regular 6 Month University (UMM Telp (0341)46431819 Language)
Faits (0341) 460782 I 460345 Website WWWummacid
36 VoCational Jalan Teluk MaIIdar AljOsari Bahasa Indonesia - Regular 1 Year Education Tromol Pos 5 Malang 65102 (I ndonesian Development TeJp (0341) 491239 Language) Center (P4lK) Website Teknol9il1 Malena httpwwwvedc ma~rtgcom
37 University of Jalan Kalimantan 37 Bahasa Indonesia - Regular 1 Year Jamber Kampus TegarSoto (Indotl8slan - Regular 6 Month (OJ) Language)
T~lp (0331) 337422 F~(0331337422
~ember68121
Email relctorunejecJd Web wwwuneJac1d Kampus IKlP Surabaya Bahasa Indonesia38 Slale University of -Regular 1 Year
Surabaya (Indonesian bull Regular 6 Month (UNESA)
~tintang Language)
Telp (031) 8290357 Surabaya - Jaws Timur
Website httDilwwwunesascld
39 Ainangga Kanpus C Mulyorejo bull Regular 1 Yaar University
SUtorejo No 59 Surabaya Bahasa IndonesiaMuham~dlYllh Telp (031) 3811966 (Indonesian - Regular 6 Month
Surabaya (UNMUH language) Surabaya)
Fax (031) 3813096 WebSite httpwINwacid
I
6
~ 49 Mulawarman Kamp1 Unmul ~Jnung Bahasa Indonesia - Regular 1Year
UnIversity Kelu8 Kotak Pas 1068 (Indonesian bull Regular 6 Month CUNMUL) Samarinda languag~) Kalimantan Timur Telp(0541) 748698
Fax (0541) 747479 WebWWWunmulac1d
50 Makasar SultanmiddotAlaudfn No 259 Bahasa Indonesia bull R~ular 1 Yeai Muhammadlyah MakaSSal (Indonesian - Regular 6 Month UnIVersity Telp (041 1881593 41nguage) (UNISMUH Fax (0411) 865588 Makasal) Web WWWunlsmuhaeid
51 UnlVerty of Jalan Perintis Kemerdekaao Bahasa Indonesia - Regular 1 Year Hasanuddln KM 10 Makasser (Indonesian - Regular 6 Month Makasar (UNHAS) Teip (0411) 584002 588200 Language)
Fax (0411) 58518B Web wwwunhasscid
52 Sam Ratulangi ~Bahaaa Indonesia ~ Regular 1 Year University Manado
KamPUB UntalBshu (IndonesianMenado North Sulawesi bull Regular 6 Month
(UNSRAT) Telp (0431) 863785 863886 language) bull Summer 3 Monthmiddot Fall (0431) a22568 middotPerlkanan amp web wwwunsrataQid Kelautan (Flsherfes
and Marine) - PerUinlan jAgricuHureJ
bull Regular 1Year Komputer
Jt Oipatl Ukur 102 118 bullTeknr~ Komputer53 Universitas (Computer
Indonasla Bandung4Q132
Technology) (UNIKOIiI) Bandung
Tep (022) 250 3J)54 bull Sistemlnfonnasi
Webwwwunlkornscid Fax (022) 253 3754
(Information System) bull Akunlansl
I(Accounting)
Bureau of Planning and Il)femationalCooperation Ministry of Educatlonand Culture
APPUCATION FORM SCHOLARS8IP FORDARMASISWA RI PROGRAMmiddot
INSTRUCTIONS
Please answer each questions clearly and completely Type or print in ink Read carefully and follow all directions Ifyou more spac~ attaoh additional pages of the same size Submit the completed fonn duly signed in lhroo copies to the Indonesian EmbassyIDipJomaticRef)resentative in your country
A PERSONAL DETAILS
I a Family name
b First name
2 Date of birth affix photo here
J Plllce ofhirth 4x6cm
4 MalclFemale
5 Nationality
6 Religion
7 Paspor Number Validity of
8 E-maH
9 a Mariml status 0 Single a Married b Do you have a husbandiwife or any dependan~
(Please give details ofnaine relationship and date of birth)
NO NAME RELATIONSHIP AGE
I
------ --- ------ ----- ------- - -- ~--
bull
D PROPOSED PROGRAM AND FlELD OF STIJDV (to be answered as detailed as possible)
I Program aD Regular I Year
bD Summer 6 Month
c 0 Regular) Month
Frst Chpice
Place ofStudy
Subject ofStudy
SecondCholu
Place ofStudy
Subject ofStudy
2 Outline your proposed field ofSludy and indicate the pracdcal use to be made of this study Ifyou are acquainted with the possibilities ofstudy offered in Indonesia iisntle institutes or projects you propose to study or the specific course you wish to attend
(Additional pa~lerfor mnre information)
)
--------~-~--~
List any siggificant publication you have written (do not attach)
l-ave you applied for any other scholarship DYes o No
Travel (List period spent away from YOllr home country)
Country visited
(~ OTHERS Experience abroad
No C0untry
~
Reason for ~isit or residel)cc abroad
Purpose
-
Dat~s
Year
-shy
w
shy
5
32 State University of Surabaya NO 6 Bahasa rndonesia - Regular 1 Year Malang Malang - Jawa Tlmur (Indonesian ~ Regular 6Month (UMrMalang Tefp1 Fax (0341) 551312 L8nguege)
Websitewwwmalang8cld
33 Teachrand Sirnpang Arjuno 14 B Regular 1 Year Educational
Institute of Budi Teip (0341) 326019 Language) UtOmoMlln9 (IKIP 323214 -Senl Budl Utomo Fax (0341) 326019 (Art) Malang) Websitlil
wwwJk~budlutomoacld
34 Polytechnic of Jalan Veleran PO BOX 04 Bahasa Indonetia - Regular 1 Year Malang Malang 65145 (Indonesfan - Regular 6 Month (POLINEMA) TelpiFax (0341) 562158 Language)
Website (tIWN poltek-malangacid
35 Malang Ja~n Raya Ttogomas24B Bahasa Inacnesia - Regular 1 Year Muhammadiyah Maiang (IndOnesian - Regular 6 Month University (UMM Telp (0341)46431819 Language)
Faits (0341) 460782 I 460345 Website WWWummacid
36 VoCational Jalan Teluk MaIIdar AljOsari Bahasa Indonesia - Regular 1 Year Education Tromol Pos 5 Malang 65102 (I ndonesian Development TeJp (0341) 491239 Language) Center (P4lK) Website Teknol9il1 Malena httpwwwvedc ma~rtgcom
37 University of Jalan Kalimantan 37 Bahasa Indonesia - Regular 1 Year Jamber Kampus TegarSoto (Indotl8slan - Regular 6 Month (OJ) Language)
T~lp (0331) 337422 F~(0331337422
~ember68121
Email relctorunejecJd Web wwwuneJac1d Kampus IKlP Surabaya Bahasa Indonesia38 Slale University of -Regular 1 Year
Surabaya (Indonesian bull Regular 6 Month (UNESA)
~tintang Language)
Telp (031) 8290357 Surabaya - Jaws Timur
Website httDilwwwunesascld
39 Ainangga Kanpus C Mulyorejo bull Regular 1 Yaar University
SUtorejo No 59 Surabaya Bahasa IndonesiaMuham~dlYllh Telp (031) 3811966 (Indonesian - Regular 6 Month
Surabaya (UNMUH language) Surabaya)
Fax (031) 3813096 WebSite httpwINwacid
I
6
~ 49 Mulawarman Kamp1 Unmul ~Jnung Bahasa Indonesia - Regular 1Year
UnIversity Kelu8 Kotak Pas 1068 (Indonesian bull Regular 6 Month CUNMUL) Samarinda languag~) Kalimantan Timur Telp(0541) 748698
Fax (0541) 747479 WebWWWunmulac1d
50 Makasar SultanmiddotAlaudfn No 259 Bahasa Indonesia bull R~ular 1 Yeai Muhammadlyah MakaSSal (Indonesian - Regular 6 Month UnIVersity Telp (041 1881593 41nguage) (UNISMUH Fax (0411) 865588 Makasal) Web WWWunlsmuhaeid
51 UnlVerty of Jalan Perintis Kemerdekaao Bahasa Indonesia - Regular 1 Year Hasanuddln KM 10 Makasser (Indonesian - Regular 6 Month Makasar (UNHAS) Teip (0411) 584002 588200 Language)
Fax (0411) 58518B Web wwwunhasscid
52 Sam Ratulangi ~Bahaaa Indonesia ~ Regular 1 Year University Manado
KamPUB UntalBshu (IndonesianMenado North Sulawesi bull Regular 6 Month
(UNSRAT) Telp (0431) 863785 863886 language) bull Summer 3 Monthmiddot Fall (0431) a22568 middotPerlkanan amp web wwwunsrataQid Kelautan (Flsherfes
and Marine) - PerUinlan jAgricuHureJ
bull Regular 1Year Komputer
Jt Oipatl Ukur 102 118 bullTeknr~ Komputer53 Universitas (Computer
Indonasla Bandung4Q132
Technology) (UNIKOIiI) Bandung
Tep (022) 250 3J)54 bull Sistemlnfonnasi
Webwwwunlkornscid Fax (022) 253 3754
(Information System) bull Akunlansl
I(Accounting)
Bureau of Planning and Il)femationalCooperation Ministry of Educatlonand Culture
APPUCATION FORM SCHOLARS8IP FORDARMASISWA RI PROGRAMmiddot
INSTRUCTIONS
Please answer each questions clearly and completely Type or print in ink Read carefully and follow all directions Ifyou more spac~ attaoh additional pages of the same size Submit the completed fonn duly signed in lhroo copies to the Indonesian EmbassyIDipJomaticRef)resentative in your country
A PERSONAL DETAILS
I a Family name
b First name
2 Date of birth affix photo here
J Plllce ofhirth 4x6cm
4 MalclFemale
5 Nationality
6 Religion
7 Paspor Number Validity of
8 E-maH
9 a Mariml status 0 Single a Married b Do you have a husbandiwife or any dependan~
(Please give details ofnaine relationship and date of birth)
NO NAME RELATIONSHIP AGE
I
------ --- ------ ----- ------- - -- ~--
bull
D PROPOSED PROGRAM AND FlELD OF STIJDV (to be answered as detailed as possible)
I Program aD Regular I Year
bD Summer 6 Month
c 0 Regular) Month
Frst Chpice
Place ofStudy
Subject ofStudy
SecondCholu
Place ofStudy
Subject ofStudy
2 Outline your proposed field ofSludy and indicate the pracdcal use to be made of this study Ifyou are acquainted with the possibilities ofstudy offered in Indonesia iisntle institutes or projects you propose to study or the specific course you wish to attend
(Additional pa~lerfor mnre information)
)
--------~-~--~
List any siggificant publication you have written (do not attach)
l-ave you applied for any other scholarship DYes o No
Travel (List period spent away from YOllr home country)
Country visited
(~ OTHERS Experience abroad
No C0untry
~
Reason for ~isit or residel)cc abroad
Purpose
-
Dat~s
Year
-shy
w
shy
5
~ 49 Mulawarman Kamp1 Unmul ~Jnung Bahasa Indonesia - Regular 1Year
UnIversity Kelu8 Kotak Pas 1068 (Indonesian bull Regular 6 Month CUNMUL) Samarinda languag~) Kalimantan Timur Telp(0541) 748698
Fax (0541) 747479 WebWWWunmulac1d
50 Makasar SultanmiddotAlaudfn No 259 Bahasa Indonesia bull R~ular 1 Yeai Muhammadlyah MakaSSal (Indonesian - Regular 6 Month UnIVersity Telp (041 1881593 41nguage) (UNISMUH Fax (0411) 865588 Makasal) Web WWWunlsmuhaeid
51 UnlVerty of Jalan Perintis Kemerdekaao Bahasa Indonesia - Regular 1 Year Hasanuddln KM 10 Makasser (Indonesian - Regular 6 Month Makasar (UNHAS) Teip (0411) 584002 588200 Language)
Fax (0411) 58518B Web wwwunhasscid
52 Sam Ratulangi ~Bahaaa Indonesia ~ Regular 1 Year University Manado
KamPUB UntalBshu (IndonesianMenado North Sulawesi bull Regular 6 Month
(UNSRAT) Telp (0431) 863785 863886 language) bull Summer 3 Monthmiddot Fall (0431) a22568 middotPerlkanan amp web wwwunsrataQid Kelautan (Flsherfes
and Marine) - PerUinlan jAgricuHureJ
bull Regular 1Year Komputer
Jt Oipatl Ukur 102 118 bullTeknr~ Komputer53 Universitas (Computer
Indonasla Bandung4Q132
Technology) (UNIKOIiI) Bandung
Tep (022) 250 3J)54 bull Sistemlnfonnasi
Webwwwunlkornscid Fax (022) 253 3754
(Information System) bull Akunlansl
I(Accounting)
Bureau of Planning and Il)femationalCooperation Ministry of Educatlonand Culture
APPUCATION FORM SCHOLARS8IP FORDARMASISWA RI PROGRAMmiddot
INSTRUCTIONS
Please answer each questions clearly and completely Type or print in ink Read carefully and follow all directions Ifyou more spac~ attaoh additional pages of the same size Submit the completed fonn duly signed in lhroo copies to the Indonesian EmbassyIDipJomaticRef)resentative in your country
A PERSONAL DETAILS
I a Family name
b First name
2 Date of birth affix photo here
J Plllce ofhirth 4x6cm
4 MalclFemale
5 Nationality
6 Religion
7 Paspor Number Validity of
8 E-maH
9 a Mariml status 0 Single a Married b Do you have a husbandiwife or any dependan~
(Please give details ofnaine relationship and date of birth)
NO NAME RELATIONSHIP AGE
I
------ --- ------ ----- ------- - -- ~--
bull
D PROPOSED PROGRAM AND FlELD OF STIJDV (to be answered as detailed as possible)
I Program aD Regular I Year
bD Summer 6 Month
c 0 Regular) Month
Frst Chpice
Place ofStudy
Subject ofStudy
SecondCholu
Place ofStudy
Subject ofStudy
2 Outline your proposed field ofSludy and indicate the pracdcal use to be made of this study Ifyou are acquainted with the possibilities ofstudy offered in Indonesia iisntle institutes or projects you propose to study or the specific course you wish to attend
(Additional pa~lerfor mnre information)
)
--------~-~--~
List any siggificant publication you have written (do not attach)
l-ave you applied for any other scholarship DYes o No
APPUCATION FORM SCHOLARS8IP FORDARMASISWA RI PROGRAMmiddot
INSTRUCTIONS
Please answer each questions clearly and completely Type or print in ink Read carefully and follow all directions Ifyou more spac~ attaoh additional pages of the same size Submit the completed fonn duly signed in lhroo copies to the Indonesian EmbassyIDipJomaticRef)resentative in your country
A PERSONAL DETAILS
I a Family name
b First name
2 Date of birth affix photo here
J Plllce ofhirth 4x6cm
4 MalclFemale
5 Nationality
6 Religion
7 Paspor Number Validity of
8 E-maH
9 a Mariml status 0 Single a Married b Do you have a husbandiwife or any dependan~
(Please give details ofnaine relationship and date of birth)
NO NAME RELATIONSHIP AGE
I
------ --- ------ ----- ------- - -- ~--
bull
D PROPOSED PROGRAM AND FlELD OF STIJDV (to be answered as detailed as possible)
I Program aD Regular I Year
bD Summer 6 Month
c 0 Regular) Month
Frst Chpice
Place ofStudy
Subject ofStudy
SecondCholu
Place ofStudy
Subject ofStudy
2 Outline your proposed field ofSludy and indicate the pracdcal use to be made of this study Ifyou are acquainted with the possibilities ofstudy offered in Indonesia iisntle institutes or projects you propose to study or the specific course you wish to attend
(Additional pa~lerfor mnre information)
)
--------~-~--~
List any siggificant publication you have written (do not attach)
l-ave you applied for any other scholarship DYes o No
APPUCATION FORM SCHOLARS8IP FORDARMASISWA RI PROGRAMmiddot
INSTRUCTIONS
Please answer each questions clearly and completely Type or print in ink Read carefully and follow all directions Ifyou more spac~ attaoh additional pages of the same size Submit the completed fonn duly signed in lhroo copies to the Indonesian EmbassyIDipJomaticRef)resentative in your country
A PERSONAL DETAILS
I a Family name
b First name
2 Date of birth affix photo here
J Plllce ofhirth 4x6cm
4 MalclFemale
5 Nationality
6 Religion
7 Paspor Number Validity of
8 E-maH
9 a Mariml status 0 Single a Married b Do you have a husbandiwife or any dependan~
(Please give details ofnaine relationship and date of birth)
NO NAME RELATIONSHIP AGE
I
------ --- ------ ----- ------- - -- ~--
bull
D PROPOSED PROGRAM AND FlELD OF STIJDV (to be answered as detailed as possible)
I Program aD Regular I Year
bD Summer 6 Month
c 0 Regular) Month
Frst Chpice
Place ofStudy
Subject ofStudy
SecondCholu
Place ofStudy
Subject ofStudy
2 Outline your proposed field ofSludy and indicate the pracdcal use to be made of this study Ifyou are acquainted with the possibilities ofstudy offered in Indonesia iisntle institutes or projects you propose to study or the specific course you wish to attend
(Additional pa~lerfor mnre information)
)
--------~-~--~
List any siggificant publication you have written (do not attach)
l-ave you applied for any other scholarship DYes o No
Travel (List period spent away from YOllr home country)
Country visited
(~ OTHERS Experience abroad
No C0untry
~
Reason for ~isit or residel)cc abroad
Purpose
-
Dat~s
Year
-shy
w
shy
5
bull
D PROPOSED PROGRAM AND FlELD OF STIJDV (to be answered as detailed as possible)
I Program aD Regular I Year
bD Summer 6 Month
c 0 Regular) Month
Frst Chpice
Place ofStudy
Subject ofStudy
SecondCholu
Place ofStudy
Subject ofStudy
2 Outline your proposed field ofSludy and indicate the pracdcal use to be made of this study Ifyou are acquainted with the possibilities ofstudy offered in Indonesia iisntle institutes or projects you propose to study or the specific course you wish to attend
(Additional pa~lerfor mnre information)
)
--------~-~--~
List any siggificant publication you have written (do not attach)
l-ave you applied for any other scholarship DYes o No