No.

Registration No.:

APPLICATION FOR MITSUI-BUSSAN SCHOLARSHIP PROGRAM FOR INDONESIA

*Application should be typewritten or hand-written clearly in English.

I, the applicant, hereby together with my parents or my guardian agree that all the information described here is obtained and utilized only by the trustee, the trustor, the managing committee members, and the trust administrator of the Program for and within the scope of the management, and that in case of grant, my name, and the name of the school, etc. will be given to the competent authorities by the Program. (sex) 1. Female (Marital Status) (same as shown in your KTP or Student card) Name in full, in block capitals: 3. Religion: Male

Single Married

2. Nationality: 4. Date and Place of Birth: 19 Year Age:

Month Day

Place of Birth:

5. The name of SMA attended: 6. Your home address

Paste your photo taken within the past

7. Your telephone number Home: 8. E-mail address: Mobile:

6 months. Put your name on the back side of the photo. (4 x 3 cm)

9. Familys address and telephone number (if different from the above):

10. Educational background:

Numbers of Year and Month of Entrance and Completion
From Cours e (IPAor IPS)

Name and Address of schooling School years

(1)

Name Location

ELEMENTARY EDUCATION Elementary School (S D)

Yrs To

(2) SECONDARY EDUCATION Lower and Upper Secondary School (SMP&SMA)

Lower (SMP)

Name Location
Yrs

From

To

Upper (SMA)

Name Location

From

Yrs

To

11. Your favorite curriculum items at your SMA, and your desired field of study in Japan:

12. Please give details of any awards or official commendations you have received:

13. Family Background:

Name
Relationshi p

Ag e

Occupation and employer/organizations name

Living 1.Togethe r 2.Separat e

1. Alive 2. Dead

Father Mother

14. If any person other than your parents is supporting your living, please answer the following; i) The person's name and relationship with you:

ii)

The persons occupation, the name of their employer/organization and the kind of duties they perform:

iii) Address and telephone number:

Date of application: 2

, 2013

Applicant's signature: Applicant's name (Block capitals):

Remarks: a. The Application should be submitted with a photo pasted onto the designated place in the first page and one additional photo 4cm x 3cm should be submitted with the Application. b. The details of required documents are described in the prospectus 6A (2) on page 4. c. The application should be submitted of clearly typed up or written in printing letters on the format which could be downloaded from the PERSADAS website. d. If there is any deficiency to the application documents, the application is not accepted.