Registration No.

: IPA/2019/04240

APPLICATION FOR MITSUI-BUSSAN SCHOLARSHIP PROGRAM FOR INDONESIA

A. PERSONAL IDENTIFICATION

ID Nasional e-KTP 3304075910010002

Kartu Siswa/No KK 3374011908090013

Name Asiyah Zakkiya

( Photo )
Place of Birth Pekalongan

Date of Birth 18-10-2001 Age 17

Marital Status Single Gender Female

Nationality Indonesia Religion Moslem

Home Address Kp Purwodinatan no. 122 Purwodinatan Semarang Tengah Semarang Jawa Tengah

Province Jawa Tengah Zip Code 50137

Phone 089697313285 Handphone 081225408697

Email Address asiyahzakkiya@gmail.com

Family's Address Kp Purwodinatan no. 122 Purwodinatan Semarang Tengah Semarang Jawa Tengah

B. FAMILY MEMBER

Occupation / Living
Name Relation Age Company Name
Position Together?
head of the
Hargo Nugroho Father 50 KPP PMA Jakarta No
inspection
section
Nani Sulastriningsih Mother 57 - - Yes

treasurer
Muhammad Zahid Brother 25 BPIB Surabaya No
expenses
financial
Ammar
Abdurrahman
Syahid Brother 22 Ombudsman RI No
statement
manager
Muthiah Khoirun Nada Sister 20 - - Yes
C. EDUCATION BACKGROUND

School Name School Address Start (year) Until (year)

SD

SD IT Bina Amal Jalan Kyai Saleh, Mugassari, Semarang Selatan, Kota Semarang, 2008 2013

Jawa Tengah 50243

SMP

SMP IT Ihsanul Fikri

Jalan Pabelan I, Pabelan, Mungkid, Magelang, Jawa Tengah 56511 2013 2016
SMA

SMA IT Ihsanul Fikri

Jalan Pabelan I, Pabelan, Mungkid, Magelang, Jawa Tengah 56551 2016 2019

IPA Score 4th semester IPA Score 5th semester

Math 88 Math 91

English 90 English 89

Chemistry 86 Chemistry 91

Physics 82 Physics 92

Language Certification

TOEFL TOEIC ILTS JLTP

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

01-02-2019

Asiyah Zakkiya