A P P L I C AT I O N F O R J A PA N E S E G OV E R N M E N T

MONBUKAGAKUSHO:MEXT) SCHOLARSHIP

Specialized Training College Students for 2013

INSTRUCTIONS
The application should be typed if possible, or neatly handwritten in block letters. )
Numbers should be in Arabic numerals. )
Year should be written using the Anno Domini system. )
Proper nouns should be written in full, and not abbreviated. )
Personal data entered in this application will only be used for scholarship selection purposes, and contact information
such as e-mail addresses will only be used for forming related human networks after the student returns home and for
sending information by the Japanese Government.
E-mail

Name in full, in your native language

(Sex)

NASUTION

(Family name/Surname)
In Roman capital letters

NASUTION

(Family name/Surname)

FADHLUL

(First name)

FADHLUL

Male

MUBARAK

Female

(Middle name)

MUBARAK

(First name)

(Marital Status)
Single

(Middle name)

(Please write your name exactly as it appears in your passport.)

Married( )

-1 Nationality -2 Possesion of Japanese nationality Yes, I have

No, I dont have

Paste your photograph
orNDONESIA
digital image taken
within the past 6

INDONESIA

months. Write your

Date of birth(

name and nationality in

19 Age
Year

Month

block letters on the

Dayas of April 1, 2013 2013 back of the photo.

Present address and telephone number, facsimile number, e-mail address

4.5 x 3.5 cm photo

E-mail

((4.5cm3.5cm))
Present address( Belakang perumdam no.38 Rt 6 Rw. 2 Kel.Kandang Mas Kec. Kampung Melayu Bengkulu
Telephone/Facsimile number( /FAX 085341078739
E-mail address fadhlulmubarak@yahoo.com
If possible, write an e-mail address where you can be contacted for periods that include the time before you come to Japan, your
stay in Japan and the period after you return home. Email
Chosen field of study and subjects in Japan
N.B. Select from Majors and Related Subjects for Fields of Study. If you enter a second choice, ensure that it is from the same field of
study as your first choice.

Field of study
First choice of subjects

Second choice of subjects

 Field of study you specialized in at high school or university

Present status (with name of school attending or employer) Student

StudentName of school
( )
in
grade / will graduate in

Year
Month
Those in employmentName of employer

Educational background:

Elementary Education
( )

Name and Address of School

Year and Month

of Entrance and

Completion

From
y
ears

Location
Name
)

To
From

and
y
ears

Location
Name
)

To
From

and
y*-1
ears

Lower Secondary School

Upper Secondary School

Location
Higher Education

Diploma or Degree awarded,

Major Subject, Skipped
years/levels

Name
)

Elementary School
Secondary Education

Duration of
Attendances

To

Name
)
)

From

Undergraduate Level

Location
To
Total
of the years schooling mentioned
above

As of April 1, 2013
(2013 4 1 )

and
*-2
y
ears

and
y
ears
and

months

Notes: Exclude kindergarten education or nursery school education. ( )

Preparatory education for university admission is included in upper secondary school.
)
If the applicant has passed the qualifying examination for admission to a university, indicate this in the blank with *-1.(
-1 )
Any school years or levels skipped should be indicated in the fourth column(Diploma or Degree awarded, Major Subject,
Skipped years and levels).(Example: Graduated high school in two years, etc.)

3
The applicant who has more than one major at his/her university should list all majors in the blank space with *-2
*-2
Language proficiency:
(1) Evaluate your ability as Excellent", Good", or Poor" in the blank space.

Reading

Japanese

Writing

Speaking

English

Others(
( )

10. Japanese language background, if any.( )

) Name and address of institution

( )

) Period of study

( )

from to
Year( )

Month( )

Year( )

Month( )

Years( )

11 Reasons for choosing to subjects entered in section 5. N.B. Specify reasons for each subjects entered in section 5. Also, ensure
that the subjects in this section are the same as the subjects entered in section 5.
( )
Subjects and reasons
First choice of subjects

Second choice of subjects

12 What kind of field are you planning to study in Japan?

( )

13. What kind of impression do you have of Japan?

14 Description of desired employment to be taken up after returning home.

( )

15. Person to be notified in applicant's home country, in case of emergency:

( )

Name in full:

Address with telephone number, facsimile number, e-mail address

E-mail )
Present Address(
Telephone/Facsimile number( /FAX
E-mail address

Occupation:

Relationship with the applicant:

name(s) of family member(s):

Father( ) Occupation( ) Nationality( )

Mother( ) Occupation( ) Nationality( )

16.Immigration Records to Japan Begin with the most recent travel to Japan
Date

Purpose

From
To
From
To

I understand and accept all the matters stated in the Application for Japanese Government (MONBUKAGAKUSHO:MEXT) Scholarship
for 2013, and hereby apply for this scholarship.
2013

Date of application:

Applicant's signature:

Applicant's name

in Roman letters capitals