No.

6
Registration No.:

APPLICATION FOR MITSUI-BUSSAN SCHOLARSHIP PROGRAM FOR INDONESIA

*Application should be typewritten or hand-written clearly in English.
I, the applicant, hereby together with my parents or my guardian agree that all the
information described here is obtained and utilized only by the trustee, the trustor, the
managing committee members, and the trust administrator of the Program for and within the
scope of the management, and that in case of grant, my name, and the name of the school,
etc. will be given to the competent authorities by the Program.

(sex)
1. Name in full, in block capitals: Male
Female
(Marital Status)
(same as shown in your KTP or Student card) Single
Married
2. Nationality: 3. Religion:

4. Date and Place of Birth:

19 Age: Place of Birth:

Year Month Day

5. The name of SMA attended:

Paste your photo

6. Your home address taken within the
past
6 months.
7. Your telephone number Put your name
Home: Mobile: on the back side
of the photo.
8. E-mail address:
(4 x 3 cm)

9. Familys address and telephone number (if different from the above):

10. Educational background:

Numbers
Year and Month Cours
of
Name and Address of schooling
of Entrance e
School years
and Completion (IPAor
IPS)
(1) Name From
ELEMENTARY EDUCATION
Elementary School Location
Yrs
(S D) To

1
(2) Name From
Lower
SECONDARY
(SMP)
EDUCATION Location
To
Yrs
Lower and Upper
Secondary School
(SMP&SMA)
Name From
Upper
(SMA)
Location
Yrs
To

11. Your favorite curriculum items at your SMA, and your desired field of study in Japan:

12. Please give details of any awards or official commendations you have received:

13. Family Background:

Living
Name Relationshi Ag Occupation and employer/organizations 1. Alive
1.Together
p e name 2. Dead
2.Separat
e
Father

Mother

14. If any person other than your parents is supporting your living, please answer the
following;

i) The person's name and relationship with you:

ii) The persons occupation, the name of their employer/organization and the kind of
duties they perform:

iii) Address and telephone number:

Date of application: , 2012

2
 Applicant's signature:

Applicant's name
(Block capitals):
Remarks:
a. The Application should be submitted with a photo pasted onto the designated place in
the first page and one additional photo 4cm x 3cm should be submitted with the
Application.
b. The details of required documents are described in the prospectus 6A (2) on page 4.
c. The application should be submitted of clearly typed up or written in printing
letters on the format which could be downloaded from the PERSADAS website.
d. If there is any deficiency to the application documents, the application is not
accepted.