DIRECTORATE OF HUMAN RESOURCES DIRECTORATE GENERAL OF HIGHER EDUCATION MINISTRY OF NATIONAL EDUCATION FORM A A.

SCHOLARSHIP Which scholarship are you applying for ? (Tick the most at propriate ONE) DDIP (France Debt Swap (germany) DIKTI-Achievers (B.U) DIKTI-Kanazawa (Japan) DIKTI-KNAW (Holland) DIKTI-NESO (Holland) DIKTI-PMRI (Holland) DIKTI REGULAR S2/S3 Scholarship Other Double-Degree Prog Specify : Other Specify : Affirmative Bidang Kesehatan

B. APPLICATION 1. have you applied ON-LINE ? : 2. What is your Registration Member C. PERSONAL DATA 1. Full name (capital letters) 2. Gender 3. Place & date of birth 4. Home address and Phone number : . YES (go to question no.2) No (skip question No.2)

: :

IRAWAN (last name) male

ERNA (First name) X Female

: TASIKMALAYA 30 JANUARY 1991 : PARAKAN SAAT STREET NO 26 0898302013 Pos code40293 Tel. : ()Mobile : : stnaira@gmail.com : : UNIVERSITAS BSI BANDUNG :NURSING

5. E-mail address 6. Employment University Faculty

Departement 7. Identification Number

: : NIP : . Karpeg : . (if avaible) (if avaible) NIDN : (if avaible) Other Employment Number : . : : Single Married

8. Rank (golongan) 9. Marital status

10. Spouses occupation

D. EDUCATION BACKGROUND 1. Please state your university, field of study, and year of degree obtained or non-degree training course(s) attended No Name of Institution Year attended Degree/Certi Field of Study ficate 1. 2. UNIVERSITAS BSI BANDUNG UNIVERSITAS BSI BANDUNG From 2008 2009 To 2012 2013 S.Kep Ners S.T NURSING TECHNICAL INFORMATIO N

2. Academic Aptitude test (Test Potensi Akademik-OTO/Bappenas), if avaible : score year obtained 3. English proficiency : International (Official) TOEFL (IBT / CBT / PBT) : score year obtained

Institusional TOEFL (ITP) : score Pra TOEFL : score IELTS : score year obtained year obtained year obtained

Please Indicate (tick) your proficiency in foreign language(s) : Fair Spoken Written (Please attach Language Proficiency Certificate(s) whenefer applicable) E. Academic Background 1. Attach your official copies of English-translated academic transcript 2. Title of your sarjana and M.S thesis : Title of undergrad thesis : Parenting parents RELATIONSHIP WITH SIBLING RIVALRY IN CHILDREN toddler (1-3 YEARS) Title of Master thesis : . . . French Good Very good Fair German Good Very good Japanese Fair Good Very good Other:.. Fair Good Very good

3. List of your research project and your position at the project mostly related to your prposed study (1. Principal Investigator, 2. Member, 3. Consultant, 4. Enumerator, or 5. Other ) No. 1. 2. 3. Year Project Title Position

4. List your recent scientific publications published in journalis No. 1. 2. 3. 4. 5. Year Article title Journals name and place of publication

5. Write names of three academic referes (former advisor, direct academic advisor, etc) No. 1. 2. 3. Name OKATIRANTI S.KP M.BIOMED SRI HAYATI S.KP M.KEP DWIZA RIANNA S.Si M.M M.KOM Relationship LECTURE LECTURE LECTURE Country INDONESIA INDONESIA INDONESIA

F. PRESENT POSITION AND DUTIES 1. Teahing responsibilities. List name of courses taught in the past two years No. Course Titles 1 LECTURE OF GHERONTIC 2 LECTURE NURSING FOR FAMILLY 3 LECTURE FOR MEDICAL SURGICAL NURSING

2. Administrative or other responsibilities Year Position

G. PROPOSED STUDY PROGRAM 1. Program 2. Field of study 3. Main research interest : Ph.D
X

Master

Joint degree

Sandwich-like Program

: MEDICAL SURGICAL NURSING : ..

23, october 2013

Mohon didaftarkan sebagai peserta test IELTS Gelombang II

01 November 2013