TETO in Indonesia

2019 年臺灣獎學金申請表
APPLICATION FORM FOR A TAIWAN SCHOLARSHIP
INSTRUCTIONS:
This application form should be typed and completed by the applicant. Each question must be answered clearly
and completely. Detailed answers are required in order to make the most appropriate arrangements. If necessary,
additional pages of the same size may be attached. 本表請申請人詳實工整填寫，慎勿遺漏，以利配合作業，如有
需要，申請人可自行以同款紙張加頁說明。

Please check. 請選以下選項

Which type of scholarship are you applying for?
□ Undergraduate Scholarship 大學獎學金
 Master Scholarship 碩士獎學金

□ Doctoral Scholarship 博士獎學金

1. PERSONAL DATA 個人基本資料

a.NAME 姓名
Title 稱謂： Mr. / Mrs. / Ms.
*Name according to
Passport Surname（Last name）姓：Banuboro

Given Name(s) 名：Abel Agusta

Chinese Name 中文姓名：-

b. CITY and COUNTRY OF

Jepara, Indonesia
BIRTH 出生.城市及國別
c. NATIONALITY 國籍
Indonesia

FATHER 父 MOTHER 母

d. PARENTS’ Name 姓名: Eko Kasiono Name 姓名: Wakhidatul Khasanah

INFORMATION
Nationality 國籍: Indonesia Nationality 國籍: Indonesia
家長資料
Place of Birth 出生地: Jepara Place of Birth 出生地: Jepara

e. CONTACT Permanent Address 永久地址：Mulyoharjo Village RT 01/RW 03, Jepara

INFORMATION Sub-District, Jepara District, Central Java, Indonesia.
聯絡地址、電話、電子 Mailing Address (If different from above)郵寄地址：(Same)
郵件
Telephone 電話：- E-mail 電子郵件：Abl.agst@gmail.com
Cell phone 手機: +62 823-2928-2699

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f. SEX 性別  Male 男 □ Female 女

g. MARITAL STATUS
婚姻狀況
 Single 單身 □ Married 已婚
h. DATE of BIRTH (Day 日／Month 月／Year 年): 20th / 08 / 1996
生日

i. PAST RESIDENCE in  Never 否; □Yes, from (dd/mm/yr) to (dd/mm/yr).是，起迄日期

TAIWAN 居住臺灣 reason for residence 居住事由:

j. Taiwan Scholarship/
Huayu Enrichment
 None 無; □Yes, from (dd/mm/yr) to (dd/mm/yr);是，起迄日期
Scholarship Award Type(s) of Scholarship Awarded:
History 臺灣獎學金/華
語文獎學金受獎紀錄

k. Others Scholarship □None 無;  Yes, from 1/9/2014 (dd/mm/yr) to 1/9/2015 (dd/mm/yr);是，起迄日期

Award History 其餘獎 5/920/16 to 5/9/2017
學金受獎記錄 Type(s) of Scholarship Awarded: Temporary Scholarship from University

l. HEALTH CONDITION
健康狀況 □ Excellent  Good □ Fair
m. CHRONIC DISEASES  None 無
慢性病 □ Yes 有─Please specify 請指明：

n. CONTACT PERSON,
IN CASE OF AN Name 姓名: - Relationship 關係: -
EMERGENCY
緊急事件聯絡人 Address 地址: -

Telephone 電話: - E-mail 電子郵件: -

Cell phone 手機: -

2. LANGUAGE PROFICIENCY 語言能力

COMPREHENSION
LANGUAGE
聽 READING 讀 WRITING 寫 SPEAKING 說
PROFICIENCY
Excellent Good Fair Excellent Good Fair Excellent Good Fair Excellent Good Fair
語言能力
優 良 可 優 良 可 優 良 可 優 良 可
  
CHINESE 

ENGLISH    

INDONESIA    

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TETO in Indonesia

3. EDUCATIONAL BACKGROUND 教育背景

Name of Institution Country &City Period of Enrollment

Level 程度
校名 地點 修業年限
Secondary Senior High School 1 Jepara
Jepara, Indonesia 2011-2014
Education 中學 (SMAN 1 Jepara)
Undergraduate Level Universitas Negeri Semarang Semarang,
2014-2018
Education 大學 (UNNES) Indonesia
Graduate Level
Education 研究所

4. REFERENCES 推薦單位 (人) 資料

Telephone , E-Mail or Mailing Address
Name 姓名 Position 職務
電話及郵電地址

Assoc. Prof. Dr. Rini Coordinator Program Cell phone 手機 : +62 818-270-087
Kusumawardani, S.T., of Civil Engineering E-mail 電子郵件: rini.kusumawardani@mail.unnes.ac.id
M.T., M.Sc. Department, UNNES
Dr. Eng. Yeri Sutopo, Coordinator Master Cell phone 手機 : +62 816-4884-232
M.Pd, M.T. Program of E-mail 電子郵件: yerisutopo@mail.unnes.ac.id
Postgraduate
Vocational
Education

5. PREVIOUS EMPLOYMENT (Use one line for each position) 工作經歷

Company/Organization Period of Responsibilities
Position 職務
機構名稱 Employment 工作說明
Site Engineer Project SEASIDE Villa 服務期間
2015-2016 Plan costs, draw detail structure,
and supervision development
Site Engineer Project Plajan Village 2018-2019 Plan costs, draw detail structure,
and supervision development

6. PRESENT EMPLOYMENT 現職狀況

a. COMPANY/ Project Plajan Village ( Pakis Aji Sub-District )
ORGANIZATION
機構名稱

b. POSITION Site Engineer

職稱
c. From 起始日期 2018

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TETO in Indonesia
Address 地址：Lebak-Suwawal Timur street No.01, Pakis Aji Sub-District, Jepara District,

d. CONTACT Central Java, Indonesia

INFORMATION Telephone 電話：(0291) - 7519939 Handphone 手機 : +62 823-1484-1799
聯絡資訊
Fax 電傳：(0291) - 7519939 E-mail 電子郵件：pakisaji@jepara.go.id

 Govt. Ministry/ □ University/ □ Govt./State-owned

e. TYPE OF Agency 政府部門 Institution 大學校院 Enterprise 公營企業
ORGANIZATION □ Locally-owned □ Joint Venture □ International □ NGO
機構種類 Enterprise 私人企業 合資企業 Enterprise 國際公司 非政府國際組織

f. PRESENT I’m not a permanent worker at Project Plajan Village, and just a Freelance worker on the
project. I have duty to calculate budget planning, carry out work, and supervise the
DUTIES & project. I started working in December 2018 to make budget planning and April 2019 for
YEARS OF project realization (carry out project and supervise the project).
EMPLOYMENT
現任職務及資歷年限

7. UNIVERSITY/DEPARTMENT, YOU PLAN TO ATTEND IN TAIWAN 擬就讀大學校院系所

University/ College and department: National Yunlin University of Science and Technology
(YunTech) / Construction Engineering or Construction and Property Engineering

8. PLEASE BRIEFLY STATE YOUR STUDY PLAN WHILE IN TAIWAN 請簡述在臺讀書計畫

In the first year of the master program in National Yunlin University of Science and
Technology, I will prepare a thesis proposal and read some related literature for my thesis
proposal. And to support the research I plan to take several courses and carry out research
collaborations with lecturers. The next step is completing my thesis proposal and primary data
collection as well as secondary data in 3-5 months. In the third semester, I plan to publish
research papers in international journals and complete my thesis. I plan to finish the master's
program on the topic of liquefaction. This topic relates to my country as one of the countries
that has a very large potential for earthquakes. As one of the researches, I will do a research on
liquefaction in Palu, Indonesia. The analysis results try to offer the type of mitigation. Actually
in 2012 a study was conducted on liquefaction in Palu, but the research was ignored and it was
actually fatal because in 2018 there was a huge phenomenon of liquefaction. For this purpose, I
prepared a concept for my research entitled "Research on the Liquefaction Potential of the Palu,
Central Sulawesi, Indonesia".

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TETO in Indonesia
9. DECLARATION: I declare that:
 I am neither concurrently an ROC national, nor an overseas compatriot of the ROC;
 I am not currently undertaking studies in Taiwan for the same educational level as the scholarship type for
which I am applying;

 I am not applying for this scholarship as an exchange student resulting from an agreement signed between
my home institution and any Taiwan university/college;

 The information I have given on this application is complete and accurate to the best of my knowledge.

10.CHECK LIST
 Application Form with Photo
 A copy of Indonesia Passport
 A copy of Kartu Keluarga
 A copy of the highest degree and academic transcripts
 A copy of admission application materials to Taiwan Scholarship Cooperative
Universities
 A copy of a language proficiency certificate
 Two letters of reference signed and sealed en envelopes. Photo copies and email
submissions of letters of recommendation will not be considered.

Applicant’s Signature

Date
25 / 02 / 2019

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