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Ministry of Education and Culture The Government of The Republic of Indonesia

This document is an application form for the Darmasiswa RI scholarship program in Indonesia. It requests personal details from the applicant, including name, date of birth, nationality, education history, language skills, proposed field and location of study, employment history, publications, previous international experience, and a declaration agreeing to the terms of the scholarship if accepted. The multi-page form instructs applicants to provide full and clear answers to help evaluate their suitability for the academic program funding.

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Tommy Nguyen
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21 views

Ministry of Education and Culture The Government of The Republic of Indonesia

This document is an application form for the Darmasiswa RI scholarship program in Indonesia. It requests personal details from the applicant, including name, date of birth, nationality, education history, language skills, proposed field and location of study, employment history, publications, previous international experience, and a declaration agreeing to the terms of the scholarship if accepted. The multi-page form instructs applicants to provide full and clear answers to help evaluate their suitability for the academic program funding.

Uploaded by

Tommy Nguyen
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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1

MINISTRY OF EDUCATION AND CULTURE


THE GOVERNMENT OF THE REPUBLIC OF INDONESIA
Jalan Jenderal Sudirman Senayan
J A K A R T A 10270
Telp/Fax: (62 021) 5724707, 5738181, 5711144 Ext. 2615
Website: http://darmasiswa.kemdikbud.go.id
E-mail: [email protected]
APPLICATION FORM
SCHOLARSHIP FOR DARMASISWA RI PROGRAM
INSTRUCTIONS
Please answer each questions clearly and completely. Type or print in ink. Read carefully and follow all
directions. If you more space, attach additional pages of the same size. Submit the completed form, duly
signed, in three copies to the Indonesian Embassy/Diplomatic Representative in your country.
A. PERSONAL DETAILS
1. a. Family name :
b. First name :
2. Date of birth :
3. Place of birth :
4. Male/Female :
5. Nationality :
6. Religion :
7. Paspor Number : Validity of :
8. E-mail :
9. a. Marital status : Single Married
b. Do you have a husband/wife or any dependants?
(Please give details of name, relationship and date of birth)
NO NAME RELATIONSHIP AGE
affix photo here
4 x 6 cm
2
10. a. Employment (present)
b. Name and address of organization :
11. Person to be notified in Indonesia and in your country in case of emergency :
In your Country:
Name :
Address:
Relationship:
In Indonesia:
Name :
Address:
Relationship:
B. EDUCATION
Name and location of
institution
Subject of study Dates
Qualifications
obtained
C. LANGUAGE: State proficiency Good-Fair-Elementary
SKILLS Indonesian English Germany French Japan
Speaking
Understanding
Writing
3
D. PROPOSED PROGRAM AND FIELD OF STUDY
(to be answered as detailed as possible)
1. Program : a. Regular 1 Year
b. Summer 6 Month
c. Regular 3 Month
First Choice:
Place of Study :
Subject of Study :
Second Choice:
Place of Study :
Subject of Study :
2. Outline your proposed field of study and indicate the practical use to be made of this
study. If you are acquainted with the possibilities of study offered in Indonesia, list the
institutes or projects you propose to study or the specific course you wish to attend.
(Additional paper for more information)
4
E. EMPLOYMENT DETAILS
YEARS DESCRIPTIONS OF OCCUPATION EMPLOYER
F. MISCELLANEOUS
List membership of professional societies and activities or public
5
List any significant publication you have written (do not attach)
Have you applied for any other scholarship: Yes No
Subject
Organization
Period from to
Travel (List period spent away from your home country)
Country visited Reason for visit or residence abroad Dates
G. OTHERS
Experience abroad
No Country Purpose Year
6
H. DECLARATION
If accepted for the scholarship, I agree;
1. to abide by the regulation of the university or college where I study
2. not changing either subject or place of study prior or upon arrival in Indonesia
3. not involve myself in any political activities during my study in Indonesia
4. not undertake any work for profit or gain during my study in Indonesia
5. to refrain myself from being pregnant and being involved in drug traffic and abuses
6. not travel out of Indonesia during the academic period and not travel out of Indonesia more
than once
7. to fully responsible for my own luggage/goods if its lost prior or upon arrival in Indonesia.
Have them in my hands custody.
8. to accept to be sent back to my country if I violate the said regulations and the stay permit
regulation in Indonesia.
I certify that the statement I have made in response to the foregoing questions are true,
Completed and correct to the best of my knowledge.
Date Signature

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