APPLICATION FOR SCHOLARSHIP

PERSONAL DATA
Full Name :

Present Address :

Permanent Address :

Photo
Telephone : 3x4 cm

E-mail Address :

Place & Date of Birth :

Sex : Male / Female

Account Number :

Bank Address :

FAMILY DATA
Name Age Education Occupation

Father

Mother

Sibling: 1

EDUCATION BACKGROUND
Graduated/ Degree
School From - To Name & Location of School Major Course GPA
Received
Elementary

Jr. High

Sr. High

University

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ORGANIZATIONAL ACTIVITIES
Name of Organization/ Activities From - To Position

TRAINING/ COURSE/ APPRENTICESHIP RECORDS

Kind of Training/ Course/
From - To Organized By Location
Apprenticeship

ACTIVITIES & HOBBIES

Membership of
Professional Association

Hobbies & Sports

Social Activities

ADDITIONAL INFORMATION (if any)

The facts stated in this Scholarship Form are true and complete to the best of my knowledge and belief.
I understand and agree to follow all the procedures, regulations, and requirements that related to Total E&P Indonesie’s Scholarship
Program.

Date: Applicant’s Signature:

N.B: Please supply all of this documents, along with this form:
 Copy of academic transcripts, from 1st semester until the last semester.
 1 photo (3x4 cm).
 Copy of the first page of your account book (that stated the Bank’s name, your name and account number).
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Date : _____________________________
Name : _____________________________

1. Why are you entitled to accept this scholarship?

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2. What is your planning after graduated from University?

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