IIEF

IELSP NO:__________ (Completed byIIEF)

Indonesia English Language Study Program (IELSP)

APPLICATION FORM
(Cohort 9 - 2011)

!I"ELINES IN COMPLETIN

T#E IELSP APPLICATION FORM

$ou must %om&lete ALL se%tions o' the a&&li%ation 'orm( I' you ha)e no ans*ers 'or %ertain se%tions+ &lease *rite, NONE. "O NOT LEA-E AN$ SECTION .LAN/. In%om&lete a&&li%ation 'orms+ in%luding those *ith 0lan1 se%tions+ *ill not 0e in%luded in the sele%tion &ro%ess( Applicants must complete the application form in English and sign it in the given space ( page 9). Applicants must attach all supporting documents required. ompleted application forms missing one or more supporting documents required !ill not "e included in the selection process. #or the list of supporting documents$ please refer to the %& '(E)T *E +,-ST section. &nl. the scores of T&E#,/ -T0 or -nternational T&E#,/ are accepted. The score must "e )& more than t!o .ears of validit. since the test date. Scores of an. 0rediction Tests are NOT accepted. ,etters of 1eference must "e put in a sealed envelope. $ou must &re&are 2 ('our) sets o' do%uments %onsisting o', o SET 1 2 &riginal completed application form 3 copies of supporting documents o SET 2 and SET 3 2 opies of SET 1 o SET 4 2 1eference letter(s) in a sealed envelope Then put all the four sets of documents in a "ig envelope2 SET 1 SET 2 SET 3 SET 4

Original completed application form + copies of supporting documents

+
COPY of SET 1

+
COPY of SET 1

REFERENCE LETTER (in a sealed envelope)

Please put all documents in one envelope.

All completed application forms (including all necessar. supporting documents) must "e received ". --E# no later than 3anuary 45+ 6544. Applicants must put the code 4IELSP7 on the left upper corner of the envelope$ and send it to2

IELSP The Indonesian International Edu%ation Foundation 8 IIEF Menara Im&erium 69th Floor Suite . 3l( #(R( Rasuna Said /a)( 4 3a1arta 46:95
All applications and documents !hich have "een su"mitted !ill "e --E#5s propert..

"OC!MENT C#EC/LIST
PLEASE ARRAN E T#ESE "OC!MENTS IN T#IS OR"ER( RE;!IRE" "OC!MENTS 1. ompleted and signed -E,S0 a&&li%ation 'orm. 2. 1 (one) color &hotogra&h 2 < = %m for the last 6 month 7 affi8 it in the provided "o8. 3. 1 (one) cop. of TOEFL>ITP or International TOEFL> s%ore. ( opies are allo!ed) 4. An o''i%ial letter o' enrollment from universit.$ stating that .ou are still an active student and have not graduated .et9not completed an. graduation process$ (including sidang skripsi) :. 1 (one) legali?ed %o&y o' your uni)ersity trans%ri&t re%ords from the 1st semester to the last semester prior to the semester .ou are currentl. in. 6. 1 (one) cop. of high s%hool di&loma (does not have to be translated) ;. 1 (one) cop. of high s%hool trans%ri&t re%ord (Daftar Nilai Ujian SM ) (does not have to be translated) <. At least 1 (one) Letter o' Re'eren%e from #acult. (em"er (use the attached form$ and put it in a sealed envelope)$ prefera"l. from .our English teacher at the universit.. Attention: please do not send the letter separately! =. 1 (one) cop. of )alid Identi'i%ation Card (/TP). %o not cut into +T0 si>e. (does not have to be translated) RECOMMEN"E" "OC!MENTS 1. opies of certificates or a!ards received 2. opies of a"stract from pu"lished articles$ research pro?ects$ papers presented at conferences$ etc. that .ou have produced

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IIEF
IELSP NO:__________ (Completed byIIEF)

I(

PERSONAL "ATA
ffi, $o%r re'ent self 'olor photograph "-,.) in this bo,

NAME, "as it appears or #ill appear on $o%r passport) (r. (s.

,ast )ame #irst )ame

2 2

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BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB A""RESS,

(iddle )ame(s) 2

PERMANENT MAILIN

(&lease note that #e are going to %se $o%r 'onta't infor(ation for all 'orresponden'e) so please be as detailed as possible) AddressBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB it. BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 0ostal ode BBBBBBBBBBBBBBBBBB State90rovince BBBBBBBBBBBBBBBBBB

Telephone "please spe'if$ $o%r area 'ode)2 BBBBBBBBBBBBBBBBBBBBBBB (o"ile 0hone "'o(p%lsor$)*BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Emergenc. 0hone num"er "'o(p%lsor$)* BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB Email "'o(p%lsor$)* BBBBBBBBBBBBBBB BBBBB

"ATE OF .IRT# ((onth9%a.9Cear)2 BBBBBBBBBBBBBBBBBBB

A E, BBBBB

EN"ER2 BBBBBBBBBBBBBBBBBB

.IRT#PLACE "Cit$) State+&rovin'e) Co%ntr$)2 BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB NATI-E LAN !A E2

BBBBBBBBBBBBBBBBBBBBBBBBBBBB

II( #EALT#
"O $O! #A-E AN$ P#$SICAL LIMITATION OR IMPAIRMENT@ $es No

I' yes+ &lease s&e%i'y, AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA #A-E $O! E-ER #A" AN$ MA3OR ILLNESS@ (e(g(, tu0er%ulosis+ he&atitis+ heart de'e%t+ dia0etes+ et%) $es No

I' yes &lease e<&lain (specify the type of illness, period of illness, any medication/treatment, and the latest condition) , AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA "O $O! #A-E AN$ ALER $@ I' yes &lease e<&lain, AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA $es No

III(

FAMIL$ "ATA
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IIEF
IELSP NO:__________ (Completed byIIEF)

II( a( Father
NAME E"!CATION , AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA , AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

OCC!PATION , AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA COMPAN$BINSTIT!TION , AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

II( 0( Mother
NAME E"!CATION , AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA , AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

OCC!PATION , AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA COMPAN$BINSTIT!TION , AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

I-( .AC/ RO!N"

In this 0o< &lease tell us a0out your &ersonal li'e and your 'amily( T#IS STATEMENT IS AN IMPORTANT PART OF $O!R APPLICATION 8 Please use additional papers if necessary

-(

E"!CATIONAL INFORMATION
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IIEF
!NI-ERSIT$ "#rite in /ahasa 0ndonesia),
IELSP NO:__________ (Completed byIIEF) AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

FAC!LT$BMA3OR "#rite in /ahasa 0ndonesia), AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA T$PE OF PRO RAM , 1egular ENTRANCE $EAR E8tension -nternational 0rogram %ou"le %egree

, AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

C!RRENT SEMESTER , AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA RA"!ATION PLAN (MonthB"ayB$ear), AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

S!MMAR$ OF Semester

RA"ES PA Num0er o' ta1en su0Ce%ts Num0er o' 'ailed su0Ce%ts

ACC!M!LATI-E

PA,

Test o' English as a Foreign Language (TOEFL>) 1 a 'op$ of s'ore report MUS2 be atta'hed 0lease ticD () the provided "o8 according to the correct ans!er2

$es+ I ha)e got my TOEFL> s%ore 0lease specif.$ !hat Dind of T&E#,/ have .ou taDenE T&E#,/-T0

-nternational T&E#,/

%ate of E8amination ((onth9%ate9Cear)2 BBB9BBB9BBBBB Score2 BBBBBBBBBBBBBBBBBB Test enter9-nstitution !here .ou tooD the test2 it.2 BBBBBBBBBBBBBB I am %urrently still *aiting 'or my TOEFL> s%ore 0lease specif.$ !hat Dind of T&E#,/ have .ou taDenE T&E#,/-T0 -nternational T&E#,/ %ate of E8amination ((onth9%ate9Cear)2 BBB9BBB9BBBBB Test enter9-nstitution !here .ou tooD the test2 it.2 BBBBBBBBBBBBBB "atta'h eviden'e if an$) e!g!* 'ertifi'ates+reports! 3rite N4N5 if $o% don6t have an$) $ear Institution From To

CO!RSESBTRAININ Name

Result

EDTRAEC!RRIC!LAR ACTI-ITIES "atta'h eviden'e if an$! 3rite N4N5 if $o% don6t have an$) A%ti)ity InstitutionBOrgani?ation
-E,S0 2@11 A 491@

$ear From To

IIEF
IELSP NO:__________ (Completed byIIEF)

OR ANIFATIONAL ACTI-ITIES BCOMM!NIT$ IN-OL-EMENT "atta'h eviden'e if an$! 3rite N4N5 if $o%
don6t have an$)

Name

S&onsor

$ear From To

Position in Organi?ation

SC#OLARS#IPS RECEI-E" "atta'h eviden'e if an$! 3rite N4N5 if $o% don6t have an$) $ear Name S&onsor From To

"es%ri&tion

ACA"EMICBNONEACA"EMIC AC#IE-EMENTS OR PRIFES "atta'h eviden'e if an$) 3rite N4N5 if $o% don6t
have an$)

A%hie)ement

Pla%e "'it$)

$ear

"es%ri&tion

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IIEF
IELSP NO:__________ (Completed byIIEF)

P!.LICATIONBARTICLES "atta'h eviden'e if an$! 3rite N4N5 if $o% don6t have an$) Ty&e Title $ear
"arti'le) paper) et')

"es%ri&tion

IF $O! #A-E TRA-ELE" OR LI-E" A.ROA"+ IN"ICATE PLACE+ P!RPOSE+ TIME AN" OT#ER NECESSAR$ INFORMATION "if $o% have never been abroad) please #rite N4N5! Do not leave this se'tion blank) Name o' Country Pur&ose "ate "7ro( 1 to) Funded 0y "es%ri&tion

LAN !A E S/ILLS, "8ate $o%rself Excellent) Good) Fair) or Poor! 0n'l%de all lang%ages in #hi'h $o% have so(e 'o(peten'e!) Mother Tongue2 Name o' Language
Reading
"5,'ellent+9ood+7air+&oor)

Griting
"5,'ellent+9ood+7air+&oor)

S&ea1ing
"5,'ellent+9ood+7air+&oor)

Please &ro)ide the name+ address and tele&hone num0er o' indi)iduals to 0e noti'ied in %ase o' emergen%y( In the !nited States In #ome Country "0f an$! 3rite N4N5 if $o% don6t have an$)

PERSONAL STATEMENT, Frite a clear and detailed description of .our reason !h. .ou !ould liDe to participate in this English stud. programG e8plain ho! -E,S0 fits !ith .our previous education9training and .our future o"?ectives. This statement should not "e a mere listing of facts and should include information a"out .our "acDground education$ practical e8perience$ special interests$ and .our purpose in appl.ing to stud.ing English in the 'nited States. Cou ma. also choose to descri"e an. significant influences on .our personal and educational development. T#IS STATEMENT IS AN IMPORTANT PART OF $O!R APPLICATION 8 Please use additional papers if
necessary

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IIEF
IELSP NO:__________ (Completed byIIEF)

In this 0o< &lease *rite *hat you thin1 are the most &ressing issues 'a%ed 0y our %ountry (Indonesia)+ and des%ri0e *hat role you *ould li1e to &lay in addressing those issues( Note* &lease li(it $o%r response to the si:e of this
te,t bo,! n$thing over this si:e #ill not displa$ or print on $o%r s%b(itted appli'ation!

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IIEF
IELSP NO:__________ (Completed byIIEF)

Ghat are your long term %areer as&irations@ Ghat s1ills do you need to a%hie)e these o0Ce%ti)es@ &lease %se
additional papers if ne'essar$!

REFERENCE. ,ist the name$ title and address including telephone num"er$ fa8 num"er and eAmail address of .our teacher !ho Dno! .ou professionall. and !ho ma. "e contacted ". mem"ers of the revie! committee. This person must "e the same from the person !hom .ou have asDed to !rite a formal letter of recommendation for .ou. Name o' Re'eree
Conta%t No( H Address (Tele&hone No(+ Fa< No(+ Email Address)

Pro'essional Title

Mailing Address

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IIEF
IELSP NO:__________ (Completed byIIEF)

CERTIFICATION AN" RELEASE A!T#ORIFATION - certif. that the information set forth in this application (including attachments) is true$ complete$ and accurate. authori>e the release of an. information necessar. to confirm and 9 or verif. this application.

Signature o' A&&li%antsI

"ate

A""ITIONAL INFORMATION #o* do you 1no* a0out IELSP &rogram@ 0u"lications (i.e. poster$ leaflet etc) )e!spaper (ailing ,ist 0resentation at 'niversities --E#5s Fe"site Alumni Education E8hi"ition &thers2

LETTER OF REFERENCE
Instru%tions 'or Griter o' Letter o' Re'eren%e ThanD .ou for agreeing to !rite this letter of recommendation for2
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IIEF
IELSP NO:__________ (Completed byIIEF)

)ame of Applicant2 BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB -t is an important input in the screening process for the -ndonesia English ,anguage Stud. 0rogram (-E,S0). -n the form of a letter$ please provide the follo!ing information a"out the applicant2 1. *o! man. .ears and in !hat capacit. have .ou Dno!n the applicantE 2. 0lease discuss the applicant5s qualifications and merits of2 a. The applicant5s special academic9professional strengths and !eaDnesses ". The applicant5s performance in e8tracurricular and9or organi>ational activities c. The applicant5s a"ilit. to use an English in dail. communications 3. 0lease include an. other information .ou ma. !ant to give in support of the applicant. 'se another sheet of paper if necessar..

Signature2 #ull name2 0rofessional Title2 %epartment9#acult.2

%ate2

'niversit.2

NOTE, Please &ut your letter inside a sealed en)elo&e and gi)e it 0a%1 to the a&&li%ant
;o%r state(ent #ill be given 'onsiderable i(portan'e b$ the revie#ers of this appli'ation and sho%ld) therefore) be as 'o(plete and detailed as possible! &lease %se additional paper if ne'essar$!

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