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BII-MAYBANK FOUNDATION SCHOLARSHIP PROGRAM

2014/2015
APPLICATION FORM

UNIVERSITAS YANG DIREKOMENDASIKAN | RECOMMENDED UNIVERSITIES

1. Perguruan Tinggi di | Universities in Indonesia
 Universitas Indonesia, Jakarta
 Institut Pertanian Bogor
 Institut Teknologi Bandung
 Universitas Padjadjaran, Bandung
 Universitas Gadjah Mada, Yogyakarta
 Institut Sepuluh Nopember, Surabaya
 Universitas Airlangga, Surabaya
 Universitas Brawijaya, Malang
 Universitas Hasanuddin, Makassar (Jurusan Hukum, Ekonomi, Agrikultur)
2. Perguruan Tinggi di | Universities in Malaysia and Singapore
 Nanyang Technological University, Singapura
 National University of Singapore
 Universiti Sains Malaysia, Kuala Lumpur
 Universiti Malaya, Kuala Lumpur
 Universiti Putera Malaysia, Kuala Lumpur
 Universiti Utara Malaysia, Kuala Lumpur

JURUSAN YANG DIREKOMENDASIKAN | RECOMMENDED FIELD OF STUDIES

(MAJOR)
 Ekonomi, Bisnis, Manajemen, Keuangan, Pemasaran, Akunting, Perbankan, Administrasi | Economy,
Business, Management, Finance, Marketing, Accounting, Banking, Administration
 Hukum | Law
 Komputer dan Teknik Informasi | Computer and Information Technology (IT)
 Sosial, Politik, Bahasa dan Komunikasi | Social, Politic, Language, Communication
 Psikologi | Psychology
 Matematika, Statistik, Aktuaria | Math, Statistic, Actuarial
 Teknik | Engineering

ALAMAT PENGIRIMAN BERKAS | ADDRESS TO SUBMIT THE APPLICATION

FORMS

By Post: Contact and Information

BII-Maybank Foundation Scholarship Tel : (+21) 2922 8888

CSR Unit, Corporate Communication Division Ext : 32461/32503
PT Bank Internasional Indonesia Tbk (BII), Email :
Sentral Senayan III, 25th Floor, scholarship@bankbii.com
Jl. Asia Afrika No. 8, Gelora Bung Karno, Senayan Website: www.bii.co.id
Jakarta Pusat 10270
By Email:

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scholarship@bankbii.com
; atau | or
bii.maybank.scholarship@gmail.com (jika ukuran file
lebih dari 1 mb | if file size is more than 1 mb)

BII-MAYBANK FOUNDATION SCHOLARSHIP 2014/2015

APPLICATION FORM

1. DATA PRIBADI *
PERSONAL DATA*
* Semua data harus sesuai dengan nama di KTP/Paspor Photograph
* All data must be the same with data in Identity Card/KTP/Passport Size 3 x 4
Nama Lengkap
     
Full Name

Jenis Kelamin
Male (L) Female (P)
Sex
Tempat & Tanggal Lahir Tempat / Place: Tanggal / Date :
Place and Date of Birth      
Tanda Identitas Pribadi KTP/Student Card:      
Identity Number Passport :      
Suku Bangsa
     
Ethnic Background
Agama
     
Religion
Warganegara
     
Citizenship
Email      
Alamat Tetap      
Permanent Address Province       Post Code      
Alamat Surat Menyurat      
Mailing Address Province       Post Code      
Telepon Rumah
     
Home Phone Number
Telepon Genggam
     
Mobile Phone Number

2. UNIVERSITAS DAN BIDANG STUDI PILIHAN

UNIVERSITY AND FIELD OF STUDIES TO CHOOSE

Universitas – Pilihan 1       Jurusan / Major :

University – Option 1      

Universitas – Pilihan 2       Jurusan / Major :

University – Option 2      
Target Waktu
      bulan / months
menyelesaikan studi
Target time to complete the Mulai Bulan / Start from the month of :      , 2014

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Sampai bulan / Until the month of :      ,      
study

Diterima Tanpa Syarat

Unconditionally Accepted (attached the acceptance letter)

Diterima (dengan syarat)

Status Penerimaan di
Universitas Pilihan Conditionally Accepted (attached the acceptance letter)
Acceptance Status in the
choice Universities

Masih Proses

in Process (Submitted the application letter to the university)

Belum Melamar

Not yet apply

3. PRESTASI AKADEMIK DI SMA

ACADEMIC ACHIEVEMENTS IN HIGH SCHOOL
Tahun Nilai
Propinsi, Kab/Kota Nilai Rata-rata Nilai Rata-rata
Nama Sekolah Selesai
Province, Kelas 2 Kelas 3 Grade
School Name Completion Semester 2 Semester 1
District/City UAN
Year
                                   

4. PRESTASI DAN PENGHARGAAN BIDANG AKADEMIK LAINNYA

OTHER ACADEMIC ACHIEVEMENT / AWARD
Tingkat Prestasi / Level of Achievement
Tahun Prestasi / Penghargaan
Year Achievement / Award Kab/Kota Provinsi Nasional Internasional
District/City Province National International
                                   
                                   
                                   

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*Ceklist √

5. KEMAMPUAN BAHASA
LANGUAGE ABILITY
BAHASA INGGRIS | ENGLISH

TOEFL
Sangat Bagus / Rata-Rata / Tidak Tahu /
Bagus / Good Dasar / Basic
Excellent Average Unidentified
Jenis | Type of TOEFL: International Lokal/ITP:
Nama | Name of Institution:      
Nilai | Score:      

IELTS
Sangat Bagus / Rata-Rata / Tidak Tahu /
Bagus / Good Dasar / Basic
Excellent Average Unidentified
Jenis | Type of IELTS: International Lokal/ITP:
Nama | Name of Institution:      
Nilai | Score:      

BAHASA LAIN | OTHER LANGUAGES

Bahasa | Language :      

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Tidak Tahu /
Bagus / Good Rata-Rata / Average Dasar / Basic
Unidentified

Sangat Bagus /
Excellent

6. INFORMASI MENGENAI ORANGTUA DAN ANGGOTA KELUARGA

INFORMATION ON PARENTS AND FAMILY MEMBERS
Pekerjaan & Nomor Status
Pendapatan per
Nama Lengkap Hubungan Umur Telepon Pernikahan
bulan
Full Name Relations Age Occupation & Phone Marriage
Income per month
Number Status
     
      Bapak | Father                  
Tel:      
     
      Ibu | Mother                  
Tel:      
     
                             
Tel:      
     
                             
Tel:      
     
                             
Tel:      
     
                             
Tel:      
     
                             
Tel:      
     
                             
Tel:      

7. APAKAH ANDA JUGA MELAMAR KE LEMBAGA LAIN UNTUK

MENDAPATKAN BEASISWA?
DID YOU APPLY SIMILAR SCHOLARSHIPS TO OTHER INSTITUTIONS OR
PROVIDERS?

Ya | Yes Tidak | No
Lembaga | Institution: 1.      
2.      
3.      

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STATEMENT OF APPLICANT | PERNYATAAN PELAMAR

Saya dengan ini menyatakan bahwa informasi yang saya berikan adalah benar dan saya memberikan kewenangan
sepenuhnya kepada Penyelenggara BII-Maybank Foundation Scholarship untuk mendapatkan bukti resmi, jika
diperlukan, dari sekolah atau lembaga pendidikan lainnya yang sedang dan telah saya ikuti. Saya memahami
sepenuhnya apabila ada pernyataan dan informasi yang dengan sengaja salah diberikan atau ada informasi yang
dipalsukan, maka lamaran beasiswa ini akan didiskualifikasi dan jika terbukti benar, maka saya sebagai pelamar
atau calon penerima atau jika nantinya diterima dapat diminta dan bersedia untuk mengundurkan diri dari program
BII-Maybank Foundation Scholarship.

I hereby declare that the information I am providing is correct to the best of my knowledge. I give a full authority
to BII-Maybank Scholarship Office to obtain official proof/evidence, if needed, from the schools or other
educational institution which I currently attending or have attended. I completely understand that if there are any
false statements or information were deliberately given or falsified, my application will be disqualified and if it is
proven, then I as a prospective applicant or recipient (if I were accepted) is willing to withdraw from receiving
the Scholarship.

Dengan mencontreng kotak ini, saya telah membaca dan setuju dengan pernyataan di

atas.
I have ticked the left box to confirm that I have read and agreed with above statement.

TANDATANGAN | SIGNATURE : _______________________________________

NAMA | NAME :      
TANGGAL | DATE :

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