KPMG ASEAN SCHOLARSHIP APPLICATION

* This application is open to Indonesian citizens only

* Kindly fill ALL mandatory fields marked with "*"

A. PERSONAL DETAILS

Full Name* RATIH AYU KUSUMANEGARA

ID Number 3371024409980001

Age* 19

Gender* FEMALE

Pemanent Mailing Address* JL ABIMANYU RT 06 RW 08 KWAYUHAN

GELANGAN MAGELANG

Home Phone No.* +6282135302938

Mobile Phone No.* +6282242517594

Email Address* SOOHEEZONE@GMAIL.COM

B. EDUCATION

1. SENIOR HIGH SCHOOL / EQUIVALENT

Name of School* SMA NEGERI 3 MAGELANG

Total UN Score* 48,5

English UN Score* 7,0

2. UNIVERSITY / EQUIVALENT

Name of School/College* UNIVERSITAS NEGERI YOGYAKARTA

Year Started* 2016

Major* ACCOUNTING

GPA / Grade* 3,69

© 2017 Siddharta Widjaja & Rekan – Registered Public Accountants, an Indonesian partnership and a member firm of the KPMG network of independent
member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name and logo are registered trademarks or trademarks of KPMG International.
C. CO-CURRICULAR ACTIVITIES

1. ORGANIZATION /CLUB /SOCIETY EXPERIENCES

Name of Institution Year From Year To Position Responsibilities

2. SPORTS / ARTS / MUSIC

Name of Institution Year From Year To Activity Presenting Level

SICMA 2016 2018 BAND HIGH

3. OTHER QUALIFICATIONS / AWARDS

Name of Award Year Given Name of Institution

D. INTERNSHIP AND PART TIME EXPERIENCES

Name of Company From To Salary Position Responsibilities

E. FAMILY BACKGROUND*

Name Relationship Occupation Employer

© 2017 Siddharta Widjaja & Rekan – Registered Public Accountants, an Indonesian partnership and a member firm of the KPMG network of independent
member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name and logo are registered trademarks or trademarks of KPMG International.
F. OTHER INFORMATION*

1. Have you ever had or are you suffering from any physical impairment, No
disease or mental illness? e.g stammering, hypertension, diabetes, asthmetics

If yes, please give details

No
2. Have you ever been convicted for a criminal offence in a Court of Law in any country?

If yes, please give details

No
3. Have you ever been convicted for bankruptcy?

If yes, please give details

I KNOW THIS SCHOLARSHIP

FROM EMAIL THAT SEND BY
4. How did you hear about this scholarship? KPMG

If other, please specify:

By submitting the details in the KPMG ASEAN Scholarship application form with KPMG, you undertake to give consent for use of your personal data by KPMG
and its related entities (hereinafter “KPMG”) for the processing of scholarship application including but not limited to verification of information provided in the
application form, conducting background checks in relation to criminal records & credit reporting, conducting reference check s, obtaining health records, academic
certificates & examination transcripts, copy of identity card & photo, etc. The processing of your personal data shall include but not limited to collection, recording,
storage, clarification (updating, modification), extraction, use, transfer (distribution, access), deletion and destruction. KPMG shall be entitled to process your
personal data by entering them into electronic databases, including them in lists (registers) and other reporting forms. Such personal data shall be stored in KPMG’s
electronic databases up to two (2) years after the date of application for the purpose of short -listing of the KPMG ASEAN Scholarship and streamlining future
applications from you before KPMG or its appointed 3rd party service provider who shall act on its behalf proceeds with the destruction of such data. The consent
for use of personal data shall be valid at all times and it may be withdrawn by you by sending a written request to the People, Performance & Culture Department
via careers@kpmg.co.id.

Application Date 26 MARCH 2018 I Agree √

The information contained herein is of a general nature and is not intended to address the circumstances of any particular in dividual or entity. Although we
endeavor to provide accurate and timely information, there can be no guarantee that such information is accurate as of the date it is received or that it will
continue to be accurate in the future. No one should act on such information without appropriate professional advice after a thorough examination of the
particular situation.

© 2017 Siddharta Widjaja & Rekan – Registered Public Accountants, an Indonesian partnership and a member firm of the KPMG network of independent
member firms affiliated with KPMG International Cooperative (“KPMG International”), a Swiss entity. All rights reserved.
The KPMG name and logo are registered trademarks or trademarks of KPMG International.