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 in ormation described here is obtained and utili!ed only by the trustee, the trustor, the managing committee members, and the trust administrator o the "rogram or and within the scope o the management, and that in case o grant, my name, and the name o the school, etc. will be gi#en to the competent authorities by the "rogram. $se%& '. *emale $)arital +tatus& $same as shown in your ,-" or +tudent card& Name in ull, in bloc( capitals: /. Religion: )ale

+ingle )arried

.. Nationality: 0. 1ate and "lace o 2irth: '3 4ear Age:

)onth 1ay

"lace o 2irth:

5. -he name o +)A attended: 6. 4our home address

"aste your photo ta(en within the past

6. 4our telephone number 7ome: 8. E-mail address: )obile:

6 months. "ut your name on the bac( side o the photo. $0 % / cm&

3. *amily9s address and telephone number $i di erent rom the abo#e&:

':. Educational bac(ground:

Numbers o schooling years 4ear and )onth o Entrance and ;ompletion
*rom ;ours e $I"Aor I"+&

Name and Address o +chool

$'&

Name <ocation

E<E)EN-AR4 E1=;A-I>N Elementary +chool $+ 1&

4rs -o

'

$.& +E;>N1AR4 E1=;A-I>N <ower and =pper +econdary +chool $+)"?+)A&

<ower $+)"&

Name <ocation
4rs

*rom

-o

=pper $+)A&

Name <ocation

*rom

4rs

-o

''. 4our a#orite curriculum items at your +)A, and your desired ield o study in @apan:

'.. "lease gi#e details o any awards or o icial commendations you ha#e recei#ed:

'/. *amily 2ac(ground:

Name
Relationshi p

Ag e

>ccupation and employerAorgani!ation9s name

<i#ing '.-ogethe r ..+eparat e

'. Ali#e .. 1ead

*ather )other

'0. I any person other than your parents is supporting your li#ing, please answer the ollowingB i& -he personCs name and relationship with you:

ii&

-he person9s occupation, the name o their employerAorgani!ation and the (ind o duties they per orm:

iii& Address and telephone number:

1ate o application: .

, .:'/

ApplicantCs signature: ApplicantCs name $2loc( capitals&:

Remarks: a. -he Application should be submitted with a photo pasted onto the designated place in the irst page and one additional photo 0cm % /cm should be submitted with the Application. b. -he details o reDuired documents are described in the prospectus 6A $.& on page 0. c. -he application should be submitted o clearly ty e! " #r $r%tte& %& r%&t%&' letters on the ormat which could be downloaded rom the "ER+A1A9+ website. d. I( t)ere %s a&y !e(%c%e&cy t# t)e a l%cat%#& !#c"me&ts* t)e a l%cat%#& %s &#t acce te!+