SCHOLARSHIP APPLICATION FORM Van Deventer-Mass Stichti This form rvill be used as an input for a grant proposal AII the information has to be the latest data Please complete this form accordingly Incomplete forms will not be considered Student Intake Personel inforoetis'u Periode 2012-2013 t\irm Your (standardized) identifi cation number Crendet Emale trfemale Check the appropriate box \eme Your name(s). Preferably first name and family (last) name. Eird dale Your date of birth (dd/mm/yyyy) Bffirplaa Your place ofbirth R€"n The region from where you originate ("asli") Sfe€t Street and house number where you live Tonn Torn rvhere you live Postal code Postal code ofplace and streel Phone Telephone number ofyour home Hp Your hand phone nurnber (current hp no.) Email Your email address. This is needed for you to log in into the SAS and for the communication rvith the PiC and VDMS Bank narr,e Your bank name, to which the scholarship iq paid. E.g. BNI - please put your name exactly as same as your name in your bank account Bank account Your Account number at that bank Level Level ofyoureducation. Choose betrveen: 52, S1, D3, SMK or SMA TOEFL score Your TOEFL score, Photo Put here your latcst photo, send it to your PIC as well. Programs for manipulating photos are Photoshop Elements (quite expensive), IrfanView (free) and GIMP (free).
This form rvill be used as an input for a grant proposalAII the information has to be the latest data
Please complete this form accordinglyIncomplete forms will not be considered
Student Intake
Personel inforoetis'u Periode 2012-2013
t\irm Your (standardized) identifi cation number
Crendet Emale trfemale Check the appropriate box
\emeYour name(s). Preferably first name and family (last)
name.
Eird dale Your date of birth (dd/mm/yyyy)
Bffirplaa Your place ofbirth
R€"n The region from where you originate ("asli")
Sfe€t Street and house number where you live
Tonn Torn rvhere you live
Postal code Postal code ofplace and streel
Phone Telephone number ofyour home
Hp Your hand phone nurnber (current hp no.)
Email
Your email address. This is needed for you to log in intothe SAS and for the communication rvith the PiC and
VDMS
Bank narr,e
Your bank name, to which the scholarship iq paid. E.g.
BNI - please put your name exactly as same as yourname in your bank account
Bank account Your Account number at that bank
LevelLevel ofyoureducation. Choose betrveen: 52, S1, D3,SMK or SMA
TOEFL score Your TOEFL score,
Photo
Put here your latcst photo, send it to your PIC as well.Programs for manipulating photos are Photoshop Elements
(quite expensive), IrfanView (free) and GIMP (free).
Studv and Work
[s1E sf ]'inal ppgPlw fill in this spee sccurotel!
Final examination expected date ( Sidang Skripsi )
DaJe ofToefl Exam Write down your toefl instituion and when
Write down your social and organization activities
with the year of your activities and position inorganization. For example: Volunteer ofEnvironment-Go Green Indonesia organization(2007-present), Cummittee of Health Teeth
program for SD Cibadak (2007), Secretary ofUniversity Choir (2008)
General informationSocial activities(wirile you are in the
university/coilege)
Grant intakeGrant intake data
Current school year:Your year ofstudy in the requested period(2nd,3d,4th,5th)
Ilstitr.rte: Institute's name
Fa,;ul4': Faculty name
ln$irute category-:
Choose: UNIV: Universitas/university (S l, S2),
ACAD: Akademi/ academy (D3), SMA: SekolahMenengah Atas, SMK: Sekolah MenengahKejuruan
Discipline: Your discipline/major of study.
IPK at the beginnh-e
ofthe school 1'ear
Your IPK score at the start ofthe requested period.
Put it in two decimals and use a decimal point (#.##
Cofinanceis:Your sources of income. Example: Parents 40%School 20% Work 10% Scholarship 30%
Familv and Financial InformationFather's Income /month
Mother's Income/month
20......
)
Rp.
Rp.
Annual Income ofthe parenis through all sources: Rp.
Ycur own income (if you are working) Rp.
Elorv do -vou go to SchoollUniversity? Public Transportation/ Motorcycle/ Car/ Walk. (Plere nake a circle on your mswer)
\f ith n'hom do you live? Parents, Uncle/Aunt, Brother/Sister, AlonelBoarding house (Kos'ftosan ).(Pleme make a ctcleon you mswer)
How much is your monthly pocket money?
Ifyou live in Boarding house(Kos-kosan) how much is the cost per month?
Note: if '.he fmily nemb:r already nrused away, rrite u R.I.P *
FORN{AL EDUCATION
Schcol/Universify i'{amePeriod ofStudy
(Start - End)
i.e: 2007-2008
SKILLSSkill(s) Excellence Average Less
Hereby I certi! that the informations above are true
Rp.
Rp
Cornputer
English
Excellence EI
Average EI
*(
Scholarshic/Financial Assistance/Loan etc.
Name of Scholarship / FinancialAssistance / Loan
Total Ambunt Drarvn
F.d\fTT,Y ilIE}{BEFS
NamePosition in
FamilySingle/l\{arrier Education Age * Occupation & Name of
the place of\l'ork
Grade in Previous Semesters:
Academic Year IP Semester lst IP Semester GPA,[PK
20... -20...20... -20..20... - 20
20... - 20
*Full name and signed
I
)
J
4
trtrutrntrnfltrtr
6
1
8
9
t0
DOCUMENTS TO BE DELIVERED
Piease enclose the below mentioned documents along with this application form and give it to the PIC in your SchoolAJniversity.
Give a check mark M on each items in the box to support youi application completeness.
A reference let'ier frcn Schooi/Universitv (Pr!ncipal/Rector/Dean) stating that you are a member ofa deprived famill'
A copy of 1,'our ID card (I(flI and KTP)
A copy of Family card membersiKartu Keluerga
A copy of Bank Account
The latest Aesdemic Transcript (KIIS) *'ith the latest GPA(hdeks Prestasi Kumulatif -lPK)
An official income statement of the parents(both government and private) or your income statementifyou are working
Surat Keterangan Kuraog }Iampu delivered by LurahIf there's no olficial ilcome stetement please mention the job and average of the parents' income inSural Kei"rangon Kurang llanpu deli,;ered b1'Lurah
Photo
A motivation letter Fith sbcii stoi)' about,vourself, your family, your school/university. Write aboutyour motivation to appl]- for a scholarship and ebout what, ou expect irom it. Signed by you
