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BII-MAYBANK SCHOLARSHIP 2013

APPLICATION FORM
UNIVERSITAS YANG DIREKOMENDASIKAN | RECOMMENDED UNIVERSITY
1. Perguruan Tinggi di | Universities in Indonesia Universitas Indonesia, Jakarta Institut Pertanian Bogor Institut Teknologi Bandung Universitas Padjadjaran, Bandung Universitas Gadjah Mada, Yogyakarta Institut Sepuluh Nopember, Surabaya

2. Perguruan Tinggi di | Universities in Malaysia and Singapore Universiti Kebangsaan Malaysia, Kuala Lumpur Universiti Sains Malaysia, Kuala Lumpur Universiti Malaya, Kuala Lumpur Nanyang Technological University, Singapura National University of Singapore

JURUSAN YANG DIREKOMENDASIKAN | RECOMMENDED FIELD OF STUDIES (MAJOR)

Ekonomi, Bisnis, Manajemen, Keuangan, Pemasaran, Akunting, Perbankan | Economy,

Business, Management, Finance, Marketing, Accounting, Banking Administrasi | Administration Hukum | Law Komputer dan Teknik Informasi | Computer and Information Technology (IT) Sosial, Politik dan Bahasa | Social, Politic and Language Komunikasi | Communication
Psikologi | Psychology Matematika, Statistik, Aktuaria | Math, Statistic, Actuarial Teknik | Engineering

ALAMAT PENGIRIMAN BERKAS | ADDRESS TO SUBMIT THE APPLICATION FORM

By Post: BII-Maybank Scholarship CSR Unit, Corporate Communication Division PT Bank Internasional Indonesia Tbk (BII), Sentral Senayan III, 25th Floor, Contact and Information Tel : (+21) 2922 8888 Ext : 32503 / 32426 Email : scholarship@bankbii.com Website: www.bii.co.id

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Jl. Asia Afrika No. 8, Gelora Bung Karno, Senayan Jakarta Pusat 10270 By Email: scholarship@bankbii.com

BII-MAYBANK SCHOLARSHIP 2013

APPLICATION FORM
Program beasiswa yang dilamar

Scholarship Program to apply

Beasiswa BII-Maybank Luar Negeri

BII-Maybank Scholarship Overseas

(TUTUP / CLOSED)

Photograph Size 3 x 4

Beasiswa BII-Maybank Dalam Negeri

BII-Maybank Scholarship Local (Indonesia)

1. DATA PRIBADI PERSONAL DATA*
* Semua data harus sesuai dengan nama di KTP/Paspor

* All data must be the same with data in Identity Card/KTP/Passport

Nama Lengkap

Full Name
Jenis Kelamin

Sex

Male (L) Tempat / Place: KTP/Student Card: Passport:

Female

(P) , Januari,

Tempat & Tanggal Lahir

Place and Date of Birth

Tanda Identitas Pribadi

Tanggal / Date :

Identity Number
Suku Bangsa

Ethnic Background
Agama

Religion
Warganegara

Citizenship
Email Alamat Tetap

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Permanent Address
Alamat Surat Menyurat Province Province Post Code Post Code

Mailing Address
Telepon Rumah

Home Phone Number

Telepon Genggam

Mobile Phone Number

2. UNIVERSITAS DAN BIDANG STUDI PILIHAN

Universitas Pilihan 1

UNIVERSITY AND FIELD OF STUDIES TO CHOOSE

Jurusan / Major :

University Option 1

Universitas Pilihan 1

Jurusan / Major

University Option 2

Target Waktu menyelesaikan studi

bulan / months Mulai Bulan / Start from the month of : Sampai bulan / Until the month of : Diterima Tanpa Syarat , 2013 ,

Time target to complete the study

Unconditionally Accepted (attached the acceptance letter)

Status Penerimaan di Universitas Pilihan Diterima (dengan syarat)

Conditionally Accepted (attached the acceptance letter)

Masih Proses

Acceptance Status in the choice Universities

in Process (Submitted the application letter to the university)

Belum Melamar

Not yet apply

KHUSUS PELAMAR PEREMPUAN Apakah Anda juga bersedia untuk dipertimbangkan sebagai pelamar program beasiswa untuk belajar di Asian University for Women in Bangladesh?

FEMALE APPLICANTS ONLY

Are you willing to be considered as an applicant for the scholarship program to study in the Asian University for Women in Bangladesh?

www.asian-university.org
Ya | Yes Tidak | No

3. PRESTASI AKADEMIK DI SMA DAN SMP

ACADEMIC ACHIEVEMENTS IN HIGH SCHOOL AND JUNIOR HIGH SCHOOL

Nama Sekolah Propinsi, Kab/Kota Tahun | Year

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School Name
SMA | High School :

Province, District/City
,

I satu | one

II dua | two Tahun Selesai |

III tiga | three

Grade
UN

Nilai |

Completion Year

Nilai Rata-Rata | Average Grade per semester Matematika | Math Fisika | Physic Kimia | Chemistry Biologi | Biology Bahasa Inggris | English Bahasa | Indonesian Ekonomi | Economics Akunting | Accounting Sosiologi | Sociology Geografi | Geography Sejarah | History *Kosongkan jika tidak ada/perlu | Leave the sections blank if not applicable SMP | Junior High School : , Tahun Selesai |

Completion Year

Grade
UN

Nilai |

Nilai Rata-Rata | Average Grade per semester Matematika | Math Ilmu Pengetahuan Alam | Science Bahasa Inggris | English Bahasa | Indonesian

4. PRESTASI DAN PENGHARGAAN BIDANG AKADEMIK LAINNYA

OTHER ACADEMIC ACHIEVEMENT / AWARD

Tahun Prestasi / Penghargaan

Lembaga Pemberi

Year

Achievement / Award

Institution gave the awards

5.

AKTIVITAS & PRESTASI BIDANG SOSIAL DAN EKSTRA KURIKULER (SEKOLAH/LUAR SEKOLAH)

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EXTRA CURRICULAR AND SOCIAL ACTIVITIES & ACHIEVEMENTS (SCHOOL / OUT OF SCHOOL)
Tahun Jabatan / Prestasi Aktivitas / Kelompok Lembaga

Year

Position or Achievement

Name of Activity / Group

Organisation / Institution

Jelaskan tugas dan tanggung jawab | Explain your tasks and responsibilities

Jelaskan tugas dan tanggung jawab | Explain your tasks and responsibilities

Jelaskan tugas dan tanggung jawab | Explain your tasks and responsibilities

Jelaskan tugas dan tanggung jawab | Explain your tasks and responsibilities

Jelaskan tugas dan tanggung jawab | Explain your tasks and responsibilities

Jelaskan tugas dan tanggung jawab | Explain your tasks and responsibilities

6. AKTIVITAS DAN PRESTASI BIDANG KEOLAHRAGAAN DAN KESENIAN

ACTIVITIES AND ACHIEVEMENTS IN SPORTS AND ARTS

Tingkat diwakili Olahraga / Kesenian

Tahun

Level represented (school, district, province, national, international)

Lembaga

Year

Sport / Arts

Institution

7. PELATIHAN YANG PERNAH DIIKUTI

TRAINING ATTENDED

Bulan, Tahun

Pelatihan | Trainings

Lembaga

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Month, Year Organisation / Institution

, , , , , , , , , ,

8. KEMAMPUAN BAHASA

LANGUAGE ABILITY

BAHASA INGGRIS | ENGLISH Sangat Bagus Tidak Tahu Excellent TOEFL Bagus Good Average Rata-Rata Basic Dasar

Unidentified

Jenis | Type of TOEFL: Nama | Name of Institution: Nilai | Mark: Sangat Bagus Tidak Tahu Excellent IELTS

International

Lokal/ITP:

Bagus Good Average

Rata-Rata Basic

Dasar

Unidentified

Jenis | Type of TOEFL: Nama | Name of Institution: Nilai | Mark: BAHASA LAIN | OTHER LANGUAGES

International

Lokal/ITP:

Bahasa | Language
Sangat Bagus Tidak Tahu Excellent Good Average Basic Unidentified Bagus Rata-Rata Dasar

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Bahasa | Language
Sangat Bagus Tidak Tahu Excellent Good Average Basic Unidentified Bagus Rata-Rata Dasar

9. INFORMASI MENGENAI ORANGTUA DAN ANGGOTA KELUARGA

INFORMATION ON PARENTS AND FAMILY MEMBERS

Hubungan Umur Pekerjaan & Nomor Telepon

Nama Lengkap

Full Name

Relations

Age

Occupation & Phone Number

Tel: Tel: Tel: Tel: Tel: Tel: Tel: Tel:

Marriage Status

Status Pernikahan

Pendapatan per bulan

Income per month

Bapak |

Father

Ibu | Mother

10. BEASISWA ATAU BANTUAN YANG SEDANG ATAU PERNAH DIDAPATKAN DARI LEMBAGA LAIN

SCHOLARSHIP OR FINANCIAL ASSISTANCE CURRENTLY IS RECEIVING OR HAVE PREVIOUSLY RECEIVED

Jumlah Jenis Beasiswa | Type of Scholarship Prestasi Akademik/Bantuan/Pinjaman Jangka waktu

Lembaga | Institution

Amount

(Academic Achievement/Bursary/Loan)

Duration

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11. APAKAH ANDA JUGA MELAMAR KE LEMBAGA LAIN UNTUK MENDAPATKAN BEASISWA?

DID YOU APPLY SIMILAR SCHOLARSHIPS TO OTHER INSTITUTIONS OR PROVIDERS?

Ya | Yes Tidak | No

Lembaga | Institution: Lembaga | Institution:

12. MOTIVASI DAN PEMBIAYAAN KULIAH

MOTIVATION AND FINANCIAL SITUATION TO STUDY

Jika Anda tidak mendapatkan BII-Maybank Scholarship untuk belajar di luar negeri, apakah Anda akan tetap melanjutkan pendidikan di luar negeri (dengan biaya sendiri)?

If you were not accepted to receive the BII-Maybank Scholarship to study overseas in Malaysia and Singapore, will you still continue studying overseas (with your own finance)?
Ya|Yes Tidak|No Jelaskan Alasannya | Explain the reason:

Jika Anda tidak mendapatkan BII-Maybank Scholarship untuk luar negeri, apakah Anda akan melanjutkan pendidikan di dalam negeri (dengan biaya sendiri)?

If you were not accepted to receive the BII-Maybank Scholarship to study overseas in Malaysia and Singapore, will you still continue studying in any Indonesian universities (with your own finance)?
Ya|Yes Tidak|No Jelaskan Alasannya | Explain the reason:

Jika Anda tidak mendapatkan BII-Maybank Scholarship untuk belajar di luar negeri, apakah Anda akan melamar BII-Maybank Scholarship untuk belajar di 6 (enam) universitas Indonesia yang direkomendasikan?

If you were not accepted to receive the BII-Maybank Scholarship to study overseas in Malaysia and Singapore, will you apply for BII-Maybank Scholarship to studying at 6 (six) recommended Indonesian Universities?
Ya|Yes Tidak|No Jelaskan Alasannya | Explain the reason:

Jika Anda tidak mendapatkan BII-Maybank Scholarship untuk belajar di dalam negeri, apakah Anda akan tetap melanjutkan pendidikan di dalam negeri (dengan biaya sendiri)?

If you were not accepted to receive the BII-Maybank Scholarship to study in the 6 (six) recommended Indonesian universities, will you still continue studying in any Indonesian universities (with your own finance)?

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Ya|Yes Tidak|No Jelaskan Alasannya | Explain the reason:

13. INFORMASI LAIN DAN KESEHATAN | HEALTH AND OTHER INFORMATION

Apakah Anda pernah terlibat tindakan kriminal? Have you ever convicted for any criminal action / behaviour?
Jelaskan | Please explain: Ya |Yes

Tidak|No Ya |Yes

Apakah Anda pernah pergi ke luar negeri? Have you ever been to overseas / foreign countries?
Jelaskan | Please explain:

Tidak|No Ya |Yes

Apakah Anda pernah dirawat di rumah sakit untuk jangka waktu yang lama (lebih dari 7 hari)?* Have you ever been treated in the hospital for a long period (more than 7 days)?
Jelaskan | Please explain:

Tidak|No Ya |Yes

Apakah Anda atau keluarga Anda mengalami kondisi sakit mental atau fisik yang membutuhkan perawatan medis secara teratur atau terus menerus?* Have you or family member ever been treated for a mental illness or physical condition which required medical treatment regularly or continuously? Jelaskan | Please explain: Apakah Anda memiliki cacat fisik tetap akibat bawaan atau kecelakaan?* Have you had any physical disabilities inherited or because of accident?
Jelaskan | Please explain:

Tidak|No Ya |Yes

Tidak|No

*these questions do not limit applicant to apply. The answer will not affect the application. It is intended to use by the scholarship office to better understand and prepare the applicants if accepted.

14. DAFTAR KELUARGA YANG BEKERJA DI BII ATAU GRUP MAYBANK

FAMILY MEMBERS WORKING IN BII OR MAYBANK GROUP

Hubungan

Nama Lengkap

Kantor / Cabang / Departemen

Full Name

Relations

Office / Branch / Department

/ / /

/ / /

15. INFORMASI MENGENAI BII-MAYBANK SCHOLARSHIP

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INFORMATION ABOUT BII-MAYBANK SCHOLARSHIP
Darimana Anda mendapatkan informasi mengenai BII-Maybank Scholarship? (Pilih maksimum 2) BII, Main Office | Kantor Pusat BII, Branch Office | Kantor Cabang Maybank Group Internet, sebutkan | mention: Ads in Newspaper | iklan di koran sebutkan| mention: Radio University Sekolah | School Pemeran Pendidikan | Education Exhibition Teman | Friends Presentasi | Presentation Iklan BBM | Broadcast BBM Lainnya | Others, sebutkan | mention:

Where did you get information about BIIMaybank Scholarship? (Choose maximum two )

16. PERNYATAAN MOTIVASI | MOTIVATION STATEMENT

Jelaskan di halaman ini mengapa Anda layak untuk mendapatkan BII-Maybank Scholarship. Pernyataan harus ditulis dengan jelas. Jelaskan pula apa yang akan Anda lakukan untuk meningkatkan kemampuan personal maupun profesional selama menempuh pendidikan dengan BIIMaybank Scholarship. Gunakan lembar tambahan jika dibutuhkan.

Please explain here the reasons you are applying for BII-Maybank Scholarship and why you are the appropriate person to receive BII-Maybank Scholarship. Please write your response legibly. Also, explain what will you do to improve your personal and professional ability during your study under BII-Maybank Scholarship. You may add additional page if needed.

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STATEMENT OF APPLICANT | PERNYATAAN PELAMAR

Saya dengan ini menyatakan bahwa informasi yang saya berikan adalah benar dan saya memberikan kewenangan sepenuhnya kepada Penyelenggara BII-Maybank Scholarship untuk mendapatkan bukti resmi, jika diperlukan, dari sekolah atau lembaga pendidikan lainnya yang sedang dan telah saya ikuti. Saya memahami sepenuhnya apabila ada pernyataan dan informasi yang dengan sengaja salah diberikan atau ada informasi yang dipalsukan, maka lamaran beasiswa ini akan didiskualifikasi dan jika

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terbukti benar, maka saya sebagai pelamar atau calon penerima atau jika nantinya diterima dapat diminta dan bersedia untuk mengundurkan diri dari program BII-Maybank Scholarship.

I hereby declare that the information I am providing is correct to the best of my knowledge. I give a full authority to BII-Maybank Scholarship Office to obtain official proof/evidence, if needed, from the schools or other educational institution which I currently attending or have attended. I completely understand that if there are any false statements or information were deliberately given or falsified, my application will be disqualified and if it is proven, then I as a prospective applicant or recipient (if I were accepted) is willing to withdraw from receiving the Scholarship.
Dengan mencontreng kotak ini, saya telah membaca dan setuju dengan pernyataan di atas.

I have ticked the left box to confirm that I have read and agreed with above statement.

TANDATANGAN | SIGNATURE : _______________________________________ NAMA | NAME TANGGAL | DATE : : ,

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