Usaid Prestasi Scholarship Program Application Form 2017 2018

8/15/2019 Usaid Prestasi Scholarship Program Application Form 2017 2018

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PRESTASI – Program to Extend Scholarships and Training to Achieve

Applicant

USAID PRESTASIScholarship Program

PRESTASI Scholarship Application

The complete application pac!age must includeChecklist of Required Documents

andator! DocumentsPlease put chec! mar! "#$ i% &ou have attached the %ollo'ing documents in support o% &our

1 )ompleted and signed application %orm 1 original and * copies

+ )erti,ed -ndergraduate )erti,cate 1 legalised cop& and * copies

* )erti,ed -ndergraduate Academic Transcript 1 legalised cop& and * copies

. Recent photographs ". / 0 234 or color$ attached to each cop&o% the application %orm

5 )op& o% valid national I6 card "7TP or . copies

08alid T9E:;< ITP or T9E:;< i2T orIE;TS= score (test date only from

. copies

>9riginal Re%erence ;etters "page 1.?1@$ in sealed en"elopes

* sets

Supplementar! DocumentsPlease put chec! mar! "#$ i% &ou are attaching the %ollo'ing documents in support o% &our

)op& o% certi,cates and a'ards 1 cop&

@)op& o% article Bournal research or coverpage o% &our publication etc(

1 cop&

1C Recent )urriculum 8itae "in English$D optional 1 cop&

Important

• 6o not submit original documents certi,cates or diplomas(

• Application %orms and attached documents 'ill not be returned(

• All documents "mandator& and3or supplementar&$ must be deliveredtogether 'ith the application %orms(

• It is not necessar& to translate academic transcripts and certi,cate"s$ intoEnglish(

• Put together all documents and arrange them into :9-R separate sets(

Please do not bind the documents( -se paper clips to separate each set(

• )ountr& destination %or stud& The -nited States o% America(

• :amilies are not recommended to accompan& scholars to the -(S(

• Scholars are not allo'ed to 'or! during their studies in the -(S(


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C#URSES A$AI%A&%E 'ASTER DE(REE %E$E% #)%*+

A. Technical Field, E)$IR#)E)T 'Code, E)$+- Areaso% stud& available :orestr& arine Studies 4ater F

Sanitation(

B. Technical Field, .I(.ER EDUCATI#) 'Code, .ED+( Areas o% stud&available

1) aster o% Education degrees in the %ollo'ing %ocus areas

G In%ormation )ommunications Technolog& "I)T$ in teachingmethodologies %or higher

educationD

G Science "including applied and social sciences$ engineering ormathematics educationD

G )urriculum development in higher educationD

G 4or!%orce development through higher education institutionsD

G Educational leadership and management in higher educationinstitutionsD

G Education polic& %or higher education

G 6isabilit& service(

2) asterHs degrees including research components( -SAI6 'ill support

researchers and scientists in higher education and research

institutions to learn research?related s!ills in topical areas such as

in%ectious diseases maternal child health marine sciences

biodiversit& climate change and other %ocus areas o% -SAI6Hs strateg&(

C. Technical Field, .EA%T. 'Code, .ealth+( Areas o% stud& available

1$ Public health

2) aternal child health and reproductive health

3) ealth Promotion and 2ehavior change

4) ospital anagement

5) Nursing anagement6) ealth s&stem strengthening

G ealth ,nancing3economics

G ealth management and polic&

G 6ata In%ormation management

G ;ogistic suppl& chain management

G ealth insurance

G Pharmaceutical Economics and Polic&

G Pharmaceutical anagement

7) 2iostatistics3Epidemiolog&

8) In%ectious 6iseases

9) Joonosis


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10) Environmental health

11) edical laborator& science

12) 2ioin%ormatics

13) edicinal )hemistr& and Pharmacolog&


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/- PERS#)A% I)F#RATI#)

Please pro"ide !our personal details e0actl! as the! appear on o1cial documents')ational ID2 Passport2 &irth Certi3cate2 etc-+- Each 3eld is mandator!-

:irst Name

iddle Name

;ast NameKI% &ou have onl& one name please 'rite do'n &our name in the Last

Please attach a recent photo(

National I6 details")hec! onl& one box belo'($

6ate o% 2irth"6633LL$

"234 or )olor$

7TP Passport Place o% 2irth . / 0

No Menderale :emale

Expir& 6ate"6633LL$

Nationalit&

)it&)urrent Residential Address "if your currentaddress is dierent from the address on yourI card! please write it below)

Province

Postal )ode

ome Telephone

No( KPlease include the code area( obile No(

Email aritalSingle arried 4ido' 3

4ido'er

4- P.*SICA% DISA&I%ITIES (if applicable)

Please describe &our disabilit&"ies$ and indicate 'hat support i% an& &ou need %rom PRESTASI inorder to be success%ul in &our %uture studies( "e(g( 'heel chair special communication devices braillecomputer other devices or assistance$


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5- EER(E)C* C#)TACT I)F#RATI#)Pro"ide details of t6o persons that 6e ma! contact in case of emergenc!

Name

Residential Address )it&

Province

Postal )ode

ome TelephoneNo(

obile No(

Email Address Relationship to

Name

Residential Address )it&

Province

Postal )ode

ome TelephoneNo(

obile No(

Email Address Relationship to

7- E)(%IS. %A)(UA(E PR#FICIE)C* Please check '8+ onl! one 9o0 9elo6 and attach a cop! of the current o1cial test

T&pe o% test T9E:;< ITP T9E:;< i2T IE;TS=

9verall score

6ate test ta!en"6633LL$

Test ;ocation

:- EDUCATI#)A% &AC;(R#U)D%ist uni"ersities and colleges !ou attended and degree's+ attained starting 6ith

the most recent- Include institutions 6here !ou are currentl! stud!ing2 ifa( Name o%

-niversit&6egree currentl&see!ing or

;ocation )it& )ountr&

6ates attendedD%rom 3LL to

)urrent or ,nalMPA

:acult& aBor

b( Name o%-niversit&

6egree 9btained


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EDUCATI#)A% &AC;(R#U)D (Continued)



MPA

:acult& aBor

c( Name o%-niversit&

6egree 9btained



MPA

:acult& aBor


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-niversit& 'ith Teachers TrainingProgram

Teachers

Emplo&mentStatus

Non )ivil Servant "NonPNS$)ivil Servant "PNS$

)asualEmplo&ee"onorer37ontra!$ )ivil

6escribe &our Bob duties and accomplishments( )omment on supervisor& responsibilities asappropriate(

b( Name o% Institution

Position

:ull Address Start 6ate"6633LL$

End 6ate"6633LL$

Telephone No(

KPlease include code area(Email

Emplo&ment )ategor&

Movernment

Institution

Research

Institution

-niversit&

Teachers TrainingInstitutePrivate SectorEmplo&

er

edia

Entrepreneur3:reela

nce School

9ther O

Emplo&mentStatus


)asualEmplo&ee"Ionorer3!ontra!$ )ivil



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c( Name o%

Institution

Positio

n:ull Address Start 6ate

"6633LL$

End 6ate"6633LL$

Telephone No(

KPlease include code area(Email

Emplo&ment )ategor&

Movernment

Institution

ResearchInstitution

-niversit&

Teachers TrainingInstitutePrivate SectorEmplo&

er

edia

Entrepreneur3:reela

nce School

9ther O

Emplo&mentStatus


)asualEmplo&ee"Ionorer3!ontra!$ )ivil


>- C#U)IT* SER$ICE ACTI$ITIESPlease descri9e an! communit! ser"ice acti"ities in 6hich !ou ha"e 9eenin"ol"ed including !our role?responsi9ilities in the e"ent's+- *ou ma! also 6ish

to indicate !our role in an! professional2 societal2 or other ci"il organi@ations in 6escribe &our role in communit& service activities or civil societ& organiations(


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- PU&%ICATI#)S%ist an! articles that !ou authored 6hich ha"e 9een pu9lished and are rele"ant to

!our application- Attach a cop! of the article's+ 6ith the co"er page of thepu9lication's+- Include additional e0amples or details on an additional page as

Title o% article

PublicationName o% Publication

)o – author"s$"i% applicable$

//- FIE%D #F TRAI)I)(For this mandator! section2 refer to the technical 3eld descriptions found in thePRESTASI 6e9site- If !our area of stud! is not included2 !ou ma! propose anotherarea of stud! that is still RE%ATED T# the Technical Field as stated on page 4-Please indicate the technical 3eld and speci3c area of stud! that !ou 6ould like

Technical 3eld Code Area of stud! Speci3c maBor

In 15C 'ords or less describe the reason"s$ 'h& &ou chose this area o% stud&(

- AARDSt an! a6ards that !ou recei"ed that are rele"ant to !our application and descri9e the name and !ear


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/4- PR#P#SED U)I$ERSIT*

PRESTASI 6orks to match scholarship recipients 6ith appropriate technicalprograms at U-S- uni"ersities- .o6e"er2 if !ou ha"e alread! identi3ed a U-S-uni"ersit! 6here !ou 6ould like to stud!2 please pro"ide details- Include

Name o%-niversit

)omplete Address

:acult&36epartment

ave &ou reQuestedadmission to thisuniversit&

Les Noave &ou received anadmission %rom theuniversit&

Les NoKI% yes attach the;etter o% Admission(

Are &ou receiving an&

%undingsupport

Les No

I% yes please describe the t&pe o% support

)ontact Person Email

/5- ESSA*SPlease ans6er each of the follo6ing questions in essa! form using /: 6ords or

a( 2rie& tell PRESTASI about &oursel% and comment on &our perception o% &our strengths and'ea!nesses(

b( 4hat challenges have &ou overcome in pursuing &our pro%essional development 4hatinsights perspectives or s!ills have &ou gained in overcoming them

c( Please describe an example 'here &ou demonstrated leadership s!ills in &our 'or! li%e or 'ithin&our communit&(


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d( Students %ace man& challenges( Please cite t'o anticipated challenges that most concern &ouabout stud&ing abroad and explain ho' &ou plan to address the challenges(

e( 6iscuss a topic that &ou are considering %or %urther research during &our asters studies(

%( 6iscuss the most important current issues in &our pro%essional ,eld( Lou ma& choose to ans'erin a general sense or %ocus on one or more issues that appl& most directl& to the context in

'hich &ou 'or!( Response to this Question ma& be +5C 'ords or less(


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/7- REFERE)CE SUAR* Please identif! three people2 6ho are not related to !ou2 and can ser"e as personal

or professional references and attest to !our skills and e0periences in leadership2technical kno6ledge2 and pro9lem sol"ing2 academics2 and?or communit! ser"ice-This reference summar! should sta! attached to the application form- A model

a( Name o%

Institution Position

Telephone Email

6escribe &our relationship to this re%eree and explain 'h& he3she 'as selected o' long have &ou!no'n this person

b( Name o%


Telephone Email


c( Name o%


Telephone Email



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o' did &ou ,rst hear about PRESTASI

2rochure or &er Social media ":aceboo! T'itter

Education :air 4ebsite or mailing list

Lour Emplo&er 9n?site Presentation at &our

Ne'spaper Radio

9thers( PleaseSpeci%&

-SAI6 supports various scholarship and communit& development programs in Indonesia(

Please chec! one o% the boxes belo' to indicate &our pre%erence in sharing in%ormation(

Lour response 'ill not aUect &our consideration %or a PRESTASI scholarship(

Les -SAI6 ma& share m& application 'ith other

-SAI63Indonesia programs( No Please do not share m&

application in%ormation 'ith other -SAI6 programs(

2& signing this %orm I certi%& that to the best o% m& !no'ledge and belie% the

in%ormation provided in all parts o% m& application is accurate and complete( I understand

that an& %alse statement or the 'ithholding o% an& relevant in%ormation ma& provide

grounds %or the 'ithdra'al o% an& oUer o% appointment or i% an& appointment has beenaccepted %or its immediate cancellation or termination(

I% a'arded I agree to participate in the Pre?Academic Training in Va!arta and i% I %ail to

complete the six?month training I 'ill reimburse all training expenses and allo'ances

incurred during the Pre?Academic Training to -SAI6 PRESTASI( I 'ill compl& 'ith all

regulations made b& the -SAI6 PRESTASI Scholarship Program(

Signature o% Applicant

Printed name o% Applicant

O 6ate


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SC.#%ARS.IP FU)DI)(

Items co"eredSourceof

Estimatedcost

Tuition :ee ;iving allo'ances in -S Pre?Academic Training Pre academic allo'ances testing "+times i2T 1 time MRE$ . -niversit& placementapplication scholar expenses "boo!s laptop

-SAI6PRESTASI

@5CCC

Travel to -S and return to Indonesiadomestic travel edical exam additionaltesting additional universit& placement

Emplo&er 5CCC

Total /2

Notes "urrency #ate 1 $S % 1&'00 I#' his is the estimated cost'

%IST #F EP%#*ERC#ITE)TS

Please note that the emplo&ers signature on this %orm con,rms the emplo&ers !no'ledgeand agreement

1. To cover items listed the table above "Source o% :unding Emplo&er$(

2. To release the applicant %rom 'or! duties in order to attend Pre?Academic Training(I% the applicant is approved b& PRESTASI to proceed to the next step the applicant'ill be reQuired to attend Pre? Academic Training in Va!arta %or a maximum o% 0months( This training is %ull time and compulsor&( *ailure of the applicant to passthe +re,-cademic rainin. may cause termination of the scholarship award(

3. To release the applicant %rom 'or! duties a%ter Pre?Academic Training to stud& in-(S %or a maximum o% +. months(

4. To process the ocial passport and exit permit reQuired %or the applicantsinternational travel %or the civil servant applicant(

Authori@ed Signature of Emplo!er

I the undersigned agree to the commitments described above(

:ull Name Signature Stamp

Position

Email

obile

6ate


15/21

)otes To the emplo!er,

1( The list o% expenses include the maximum expenses indicated %or the applicanttraining and travel( Some expenses ma& not be needed "additional T9E:; i2Tand MRE$ or ma& cost less "no domestic tic!et needed i% the applicant reside in Vabodetabe!$(

2. Pa&ment or expenses are made 'hen activities are implemented "not as one lumpsum$(

3. The emplo&ee 'ill provide pa&ment %or expenses directl& to the applicantDno monies 'ill be trans%erred to PRESTASI(


16/21

C#)FIDE)TIA% %ETTER #F REFERE)CE

Than! &ou %or &our 'illingness to serve as a re%erent %or an applicant %or a -SAI6PRESTASI Scholarship(

M-I6E;INES

1( )omplete the ,ve Questions in English either b& t&ping or b& hand'riting

+ I% a Question is not applicable to &our relationship 'ith the applicant please'rite Wn3aX "not

* :or con,dentialit& insert the letter into an envelope seal and sign it acrossthe border o% the tongue be%ore giving it to the applicant

.( prestasiYiie%(or(id5( :or an& in%ormation or clari,cation contact prestasiYiie%(or(id or call Z0+

Name o% applicant

1( 6escribe &our relationship to the applicant and include ho' long &ou have!no'n this person(

+( Please comment on the applicants strengths 'ea!nesses level o%emotional and3or

pro%essional maturit& and abilit& to 'or! 'ith others(

*( 6escribe the applicants pro%essional !no'ledge o% his3her technical ,eldDabilit& to appl& that !no'ledge to ne' situationsD and abilit& to de,ne andsolve problems( Please comment i% applicable(

mailto:[email protected]:[email protected]:[email protected]:[email protected]


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.( Please share an experience 'here the applicant demonstrated initiative( :orexample 'here he3she led others in an academic or 'or!?related proBect or

at a communit& event(

5( Please provide an& additional %acts or comments that ma& help PRESTASIevaluate the applicant(

Re%erents Institution

Name and Title o% Re%erent

Signature

6ate


18/21



M-I6E;INES





Name o% applicant







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Signature

6ate


20/21



M-I6E;INES





Name o% applicant







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Signature

6ate

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