FULBRIGHT-DIKTI SCHOLARSHIP PROGRAMS

PRELIMINARY APPLICATION FORM

(PLEASE TYPE OR WRITE IN CAPITAL LETTERS)
Affix your recent self
3 x 4 cms photograph
in this box.

Personal Information
Name:
__________________________________________________________________________________________
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Citizenship:
__________________________________________________________________________________________
Place and date of birth:
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Mailing Address:
____________________________________________________________________________________
__________________________________________________________________________________________
___________
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(Office): ______________________ Fax: _______________________
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(Home)/Cell-phone:

Email:

Proposed field of study:

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Program you are applying for
Please check appropriate box.
M.A. PROGRAM

FULBRIGHT-DIKTI MASTERS DEGREE PROGRAM

PH.D. PROGRAM

FULBRIGHT-DIKTI SCHOLARSHIP PROGRAM

RESEARCH PROGRAMS

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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

FULBRIGHT-DIKTI DOCTORAL DISSERTATION RESEARCH (DDR) AWARD PROGRAM. (Applicants must have
completed the required coursework. Please put a check mark (V), if you ___Have outlined dissertation proposal;
___Have a dissertation adviser in Indonesia (please attach a letter of support from the adviser);___Have
contacted American university for potential adviser.)

FULBRIGHT-DIKTI SENIOR RESEARCH AWARD PROGRAM.

Academic History**
University/Institute Attended after High School

Years Attended

Degree Obtained/Expected GPA/IPK

From

(incl. Field of Study)

To

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_________________________

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Scholastic Distinctions/Honors you have received**

Year

Distinction/Honors

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Standardized Test Scores (Please attach a photocopy of each test.

Test results should not be older than 2 years)

Test

Score

Date taken

TOEFL: International Institutional IELTS*

______________________
(Note: Senior Research Program applicants do not need a test score)

____________________

Degree student candidates must take the Graduate Record Examination (GRE for all fields except Law and Business) or Graduate
Management Admission Test (GMAT for business administration, finance, accounting) if they are selected. It is recommended that applicants
begin to familiarize themselves with the above test.

Professional History**
List your work experience since university graduation. Start with the most current one.
Dates (ToFrom) Position
Name of Institution
(indicate month)

Responsibility

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____________________________________

___________________________

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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

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Social and Community Involvement**
List professional, societal, fraternities or other organizations in which you now hold membership or in which you have been active in the past.
(Indicate if you have held an elective office):
Year
Position/Organization
Responsibility

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Research Projects Completed**

Project name

Position in the project

Sponsored by

Date

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Articles/Books/Unpublished Papers/Thesis/Dissertation**
Title of publication

Subject

Type***

Date

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If you have ever traveled or lived outside Indonesia, please specify dates, countries and purpose**
Dates

Country

Purpose

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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

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Please indicate if you have previously applied for a U.S. visa and the status of that application
Dates

Type of Visa Applied for

Status of that Application

____________________
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Study Objective (for Masters applicants only)
This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a one page (please do
not exceed the 1 page limit) of a clear and detailed description of your study objectives. Give your reason for wanting to
pursue them in the U.S. Describe the kind of program you expect to undertake, and explain how your proposed field of study fits
in with your educational background, your future objectives, and your future involvement in community development.

Study Objective and Research Proposal

(for Doctoral/Ph.D and Doctoral Dissertation Research applicants only)
This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a one page (please do
not exceed the 1 page limit) of a clear and detailed description of your study objectives. Give your reason for wanting to
pursue them in the U.S. Describe the kind of program you expect to undertake, and explain how your proposed field of study fits
in with your educational background, your future objectives, and your future involvement in community development. In addition to
the Study Objective, please add three-five page Research Proposal. (See below)

Research Proposal
(for Senior Research Program applicants only)
This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a three to five-page
Research Proposal. (See below)

Research Proposal (for both Doctoral Dissertation Research and Senior Research Program)
Project title:
_________________________________________________________________________________________________________________
__

This section is very IMPORTANT .

Please write, between three to five pages, a clear and detailed description of your
proposed activity including the following items: (1) Background: When possible, place the project in academic or professional context by
referring to the major work by others on the topic. In some cases this can be aided by use of a select bibliography.
(2) Objective: Define clearly the aims of the project. (3) Methodology: Describe the project and explain the approach and methods you will
follow. (4) Significance: Explain the significance of the project for the field, your own professional development, and home country. (5)
Others: (a) Indicate why residence in the United States is necessary for accomplishment of the project.
(b) Explain how your project can be completed within the time period requested.

How do you learn about the Fulbright-DIKTI Scholarship program

Newspaper ads Friend Website Other: __________________________________________________________________

If you are currently applying for other scholarship programs, please specify program and status of your
application
Name of Program

Type of Program Applied

__________________________________
_____________________________

Status of Application

__________________________________

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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

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Declaration
I hereby certify that the information I have provided on this application form and in any attached materials is accurate and true to
the best of my knowledge and belief, and I agree to notify DIKTI of any change in the above information or of any further information
that might affect my eligibility for consideration as a prospective recipient of the Fulbright Scholarship award.
I understand that by completing this application form there is no assurance that I will be awarded a grant.
I understand that grant funds are not sufficient to cover travel or support for my family and I will make necessary arrangements for
the living expenses in Indonesia while I am away or in the U.S. if they wish to join me.
I have no objection to publicity about my selection for a Fulbright-DIKTI Scholarship.

Signature: ______________________________________
____________________________________________

Date:

Note:
*IELTS score of 5.5 is approximately equal to 525 on the TOEFL; 6.0 = 550; 6.5 = 575; 7.0 = 600
**Please attach additional pages if necessary.
***Articles, books, unpublished paper/ thesis/dissertation
The Fulbright-DIKTI scholarship program was launched in 2009 by the Ministry of National Education Directorate General of
Higher Education (DIKTI) in cooperation with The American-Indonesian Exchange Foundation (AMINEF) to offer Higher
Education Scholarships to permanent Indonesian faculty members of state and private universities to pursue full time graduate
study or conduct doctoral dissertation or post doctoral research programs at U.S universities in any fields of study with the
exception of medical sciences related to patient care or medical training. Foreign medical doctors may be eligible to apply if they
are engaged in observation and research.

THIS FORM IS TO BE FILLED OUT COMPLETELY AND ACCURATELY.

WE REGRET INCOMPLETE APPLICATION WILL NOT BE CONSIDERED.
APPLICATION SUMMARY AND CHECKLIST
A correctly prepared application packet facilitates the review process and increases your chance for an
award. It is your responsility to ensure that the application is complete before submitting it to the
following address:
Fulbright-DIKTI Scholarship Program
Direktorat Ketenagaan
Direktorat Jenderal Pendidikan Tinggi
Departemen Pendidikan Nasional
u.p. Direktur Ketenagaan
Jl. Pintu I Senayan, Lt. 5
Jakarta 10002
A complete application includes:

Application form (4 pages)

Study Objective (Masters and Ph.D. Degree Programs)
Detailed Research Proposal (Ph.D. Degree, Doctoral Dissertation Research and Senior Research
Programs)
Copy of most recent, less than 2 years old, TOEFL (either ITP or iBT) or IELTS score report (Note:
Senior Research Program applicants do not need a test score)
One letter of reference
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FULBRIGHT-DIKTI PRELIMINARY APPLICATION FORM

One letter of support from dissertation adviser (Note: only for Doctoral Dissertation Research
Program)
Copy of academic transcripts and diploma (Note: doesnt apply to applicants to the Senior
Research Program)
Copy of identity card (KTP or passport)

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