APPLICATION FOR ACEH SCHOLARSHIP

COMPLETED APPLICATION FORMS

C/o: Bureau for Education and Culture, Third Floor, Office of the Governor of Aceh Lampineung, Banda Aceh, INDONESIA

Bureau for Education & Culture Office of Governor of Aceh

YEAR 2010010

I. 1. 2. 3. 4. 5. 6. 7. 8. II. No 1. 2. 3. 4. 5. 6. 7. III. No 1. 2. 3. IV V No 1. 2. 3. VI No 1. 2. VII VIII

PROFILE OF APPLICANT Name Place and Date of Birth Name of Father Name of Mother Name of Wife/Husband(*) Dependant Home Address Office Address EDUCATIONAL BACKGROUNDS Level of Education Primary School (Grade 1-6) Junior High School (Grade 7-9) Senior High School (Grade 10-12) Training/Sertifikat(*) Diploma I/II/III(*) Undergraduate (4-year degree) Graduate (Masters Degree) WORKING EXPERIENCES Name of Institution/Departement/Agency Address of Institution/Department/Agency Position/Title Name of School Address Areas of Study (if Available) GPA HP Phone Sex: Male Female

DEGREE PROGRAM TO BE PURSUED NAME OF UNIVERSITY/INSTITUTION TO BE APPLIED Name of University/Institution

DIPLOMA

S1

S-2

S-3

City

Country

Areas of Study

NAME OF ACADEMIC ADVISOR AT THE UNIVERSITY TO BE APPLIED (IF ANY) Name Department Address Telp./E-mail/Handphone

MODE OF EDUCATION/PROGRAM (Only for Masters and Ph.D Programs) 1. Course Work 2. Mixed Mode GIVE US REASONS WHY YOU ARE PLANNING TO PURSUE YOUR STUDY IN THIS AREAS OF STUDY

3. By Research

IX No

AWARDS RECEIVED Awarding Agency/Institution For what achievement Year Level of Awards

DO YOU THINK YOUR PROPOSED PLAN AREA OF STUDY RELEVANT TO THE NEEDS OF HUMAN RESOURCES FOR THE PROVINCE?
Please specify the relevancy between Your Areas of Study to the presence and future development of the Province of Aceh.

XI

AFTER COMPLETING YOUR STUDY, ARE YOU WILLING TO RETURN AND WORK IN ACEH. 1.YES 2.NO If YES, where are you going to work. Specify names of institution and agency 1. 2.

XII 1. XIII

WHY ARE YOU PREPARING TO WORK OR BE PLACED AT THE ABOVE AGENCY: IF YOU ARE MARRIED, WHO WILL FINANCE WIFE AND FAMILY MEMBERS: 1.Own fund Name of family members to be notified should there be an emergency: Name: Address: No.HP/Tlpn. 2. [ ] NO 2.Relative 3.Others

XIV

HAVE YOU TAKEN ANY ENGLISH AND OTHERLANGUAGE PROFICIENCY TEST? 1. [ ] YES Date taken : Place: Score : Expires in: 2. [ ] NO 2. 4. How Long: Which hospital: For what : Name of medical doctor:

XV

HAVE YOU EVER BEEN HOSPITALIZED? 1. [ ] YES 1. 3.

Banda Aceh,

2010

Name of Applicant