Section C

User ID Email
UWC2019-1A04B5 ipanrilan16@gmail.com

Scholarship Information on Selected Schools

Selected Schools Total Yearly Fee (Rp.) Funded Portion (%)

1. United World College of 587,000,000 0
the Atlantic, UK
2. Lester B. Pearson 617,699,500 100
United World College of
the Pacific, Canada
3. United World College of To be determined 0
South East Asia,
Singapore

Attention: Parents/guardians, please review the above scholarship information

prior to signing this document.

Parents/Guardian Info
Father or Legal Guardian Mother or Legal Guardian
Full Name RUSDITA DARNI
Date of Birth Sat, 07/07/1973 Thu, 05/05/1977
Address Siwalan, Patimban, Siwalan, Patimban,
Pusakanagara Pusakanagara
Subang west Java. Subang Jawa barat
Home Phone 021 4696612 021 4696612
Mobile Phone 082350217155 082350217155
Email
Occupation Warga negara Indonesia Warga negara Indonesia
Institution The farmer Ibu rumah tangga
Position / Grade
Net Income / Month 1000000

Please give a brief description of any medical or mental health concerns,

physical impairments, serious illnesses or allergies that the applicant may
have had

Section C - 1 of 2
 Please list any special dietary requirements that the applicant may have for
medical, religious or ethical reasons?

Additional Note:

We, the parents/guardian agree to cover the remaining cost of school fee,
and will be committed for the two-year program.

Father/Legal Guardian Signature Mother/Legal Guardian Signature

Section C - 2 of 2

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