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International Environmental Research Institute

International Internship Program

APPLICATION FORM
1. Personal Details
Applicant full name in English (as shown in your passport)
Surname/Family Name Given Name

Burahim Ridhwan Haliq

Date of birth (yyyy/mm/dd) Gender
1992/03/07
M (X) F( )
Place of birth Nationality
Balikpapan Indonesia

Mailing address (permanent address)

Jl. Praja Mukti No.28 RT 27 Kelurahan Sepinggan Baru Kecamatan Balikpapan Selatan Kota Balikpapan

Mailing address (current address)

Jl. Praja Mukti No.28 RT 27 Kelurahan Sepinggan Baru Kecamatan Balikpapan Selatan Kota Balikpapan

Marital status (single / married / divorced / widowed) Email address

married ridhwanhaliq@lecturer.itk.ac.id

Contact no. (with country and area code) Fax no. (with country and area code)
+62 813 47511131

2. Please list a name of the person to be notified, in case of emergency

Name
Eka Ramadhani

Mailing address
Jl. Praja Mukti No.28 RT 27 Kelurahan Sepinggan Baru Kecamatan Balikpapan Selatan Kota Balikpapan

Contact no.
+62 898 2225 323

3. Knowledge of languages. Mother language: ______________________________

Read Write Speak
Other languages Not Not
Easily Easily Not easily Easily
easily easily
English V V V

International Environmental Research Institute, Gwangju Institute of Science and Technology

Room no. 322, Environmental Samsung Building 123 Cheomdangwagi-ro (Oryong-dong) Buk-gu, 61005
Republic of Korea Tel (+8262) 715-3366 Email:ieri@gist.ac.kr Website: http://ieri.gist.ac.kr/eng/index.php
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4. Higher education
Institution Attendance from / to
Degree Major subject of
(Name, place and
(Date awarded) From To study
country)
Institut Teknologi
Sepuluh
Nopember,
Surabaya, Material and
Indonesia March, 15th 2015 2013 2015 Metallurgi
Engineering

Current status (Bachelors students / MSc. Students / Ph.D. students / Post-doctoral)

Lecturer and Ph.D Candidate

Current affiliation
Institut Teknologi Kalimantan

Academic advisor
Prof. Ir. Budi Santosa Purwokartiko, Ph.D

5. Employment (Please provide your employment history, if any)

1. Lecturer in Material and Metallurgical Engineering ITK

2. PT. Adhi Karya Persero Tbk.
3.
6. Internship Experience in South Korea (Please provide the name of the university
/ institute / company and the internship program participated, if any)
1.
2.
3.
7. Other Information
a) Scholarships

b) SCI Publications
The Effect of Filler Composition and Shape to Sound Capability Insulation and Modulus
Elasticity Natural Fiber Galam Wood (Melaleuca Leucadendra)-Polyester

The Effect of Calcination Temperature Variation on the Sensitivity of CO Gas Sensor from Zinc
Oxide Material by Hydrothermal Process

International Environmental Research Institute, Gwangju Institute of Science and Technology

Room no. 322, Environmental Samsung Building 123 Cheomdangwagi-ro (Oryong-dong) Buk-gu, 61005
Republic of Korea Tel (+8262) 715-3366 Email:ieri@gist.ac.kr Website: http://ieri.gist.ac.kr/eng/index.php
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Dosimetric Characteristics of Agate Stones for High Dose Dosimeters

c) Have you ever been convicted, fined or imprisoned for the violation of any law?
Yes ( ) No (X)
If yes, please give full details in an attached statement.

8. Please indicate your availability for the internship.

Spring: Early Feb - End of June 2020 / Fall: Early August - End of December 2020

Spring semester (X) Fall semester ( )

9. Preferred Laboratory
Please suggest 3 professors in School of Earth Science and Environmental Engineering
that you wish to be assigned in the order of preference (1 top to 3 lowest)
A list of professors can be found here https://env1.gist.ac.kr/env1/  laboratories  click on each
laboratory website
a. Prof. Heechul Choi

b. Prof. In Seop Chang

c. Prof. Yunho Lee

10. References / Academic advisor (Person who write your recommendation letter)
Please write the detail information of the person who write your recommendation letter
(he /she must not related to you who are familiar with your academic qualifications and
character), and who have agreed to forward a letter of reference directly to IERI.
Title Full name
Professor Prof. Ir. Budi Santosa Purwokartiko, Ph.D

Email address Contact no. (with country and area code)

rektor@itk.ac.id +62 838 5717 0651

Profession
Rector

11. Agreement
I have read and fully understand the guidelines and conditions of the International
Environmental Research Institute International Internship Program, which include the
following:
(a) that I am responsible for obtaining necessary visas and required documents as
requested by IERI.
(b) that I shall fulfill the final report and presentation as requested by IERI by the end of
the internship program.

I CERTIFY that the foregoing statements and answers are true, complete and correct to
the best of my knowledge and belief.

Date : November, 3th 2020

International Environmental Research Institute, Gwangju Institute of Science and Technology

Room no. 322, Environmental Samsung Building 123 Cheomdangwagi-ro (Oryong-dong) Buk-gu, 61005
Republic of Korea Tel (+8262) 715-3366 Email:ieri@gist.ac.kr Website: http://ieri.gist.ac.kr/eng/index.php
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Full name : Ridhwan Haliq Signature:

International Environmental Research Institute, Gwangju Institute of Science and Technology

Room no. 322, Environmental Samsung Building 123 Cheomdangwagi-ro (Oryong-dong) Buk-gu, 61005
Republic of Korea Tel (+8262) 715-3366 Email:ieri@gist.ac.kr Website: http://ieri.gist.ac.kr/eng/index.php