Fulbright Student Application Form

FULBRIGHT VISITING
STUDENT PROGRAM
PRELIMINARY
APPLICATION FORM
FULBRIGHT PRELIMINARY APPLICATION FORM
FULBRIGHT
PRELIMINARY APPLICATION FORM Affix a recent
3 x 4 cm photograph
(PLEASE TYPE, DO NOT WRITE) here.
PERSONAL INFORMATION
NAME
Please provide your name as it appears on your ID (KTP/Passport)
Prefix : Click or tap here to enter text.
First/Given Name : Click or tap here to enter text.
Middle Name(s) : Click or tap here to enter text.
Last/Family Name : Click or tap here to enter text.
Suffix (Jr./Sr.I/II/II) : Click or tap here to enter text.
NAME ON PREVIOUS RECORD

Please provide your name if listed on previous records differently than above.
Middle Name(s) : Click or tap here to enter text.
BIOGRAPHICAL INFORMATION
Birthdate (e.g. 01 May 1980) : Click or tap to enter a date.
City of Birth : Click or tap here to enter text.
Country of Birth : Click or tap here to enter text.
Sex (male/female) Click or tap here to enter text.
:
Physical Impairment : Click or tap here to enter text.
Please describe any physical impairment you may have. (This information is gathered for statistical purposes and to ensure appropriate
placement. The Fulbright Program does not discriminate on the basis of physical impairment).
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CITIZENSHIP INFORMATION
Country of Citizenship : Click or tap here to enter text.
Additional Countries in Which You Hold Citizenship: Click or tap here to enter text.
Country of Permanent Residence : Click or tap here to enter text.
National Identification Number (KTP/Passport) : Click or tap here to enter text.
CONTACT INFORMATION
ADDRESSES
Permanent Address (DO NOT TRANSLATE the address into English)
Country : Click or tap here to enter text.
Street : Click or tap here to enter text.
City : Click or tap here to enter text.
Province : Click or tap here to enter text.
Postal Code : Click or tap here to enter text.
Current Mailing Address (DO NOT TRANSLATE the address into English)
Valid From : Click or tap to enter a date.
Valid To : Click or tap to enter a date.
TELEPHONE NUMBERS
Please be sure to include the local code along with your number (e.g. +62812345678, 021 8789995)
Cell Phone Number 1 : Click or tap here to enter text.
Cell Phone Number 2 : Click or tap here to enter text.
Home Phone Number : Click or tap here to enter text.
Work Phone Number : Click or tap here to enter text.
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E-MAIL
Please provide a primary and secondary e-mail address (e.g. professional, university, etc.) in case we have difficulties contacting
you at the primary e-mail address. Please note that all system-generated messages will be sent to the primary e-mail address.
Primary : Click or tap here to enter text.
Secondary : Click or tap here to enter text.
EMERGENCY CONTACT INFORMATION

The individuals listed below may be contacted in the event of an emergency while undertaking activities related to this
grant opportunity, including any possible travel required for interviews in Indonesia.
Contact 1
Phone Number : Click or tap here to enter text.
E-mail : Click or tap here to enter text.
Relationship to You : Click or tap here to enter text.
Contact 2
Phone Number : Click or tap here to enter text.
Relationship to You : Click or tap here to enter text.
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ACADEMIC & PROFESSIONAL INFORMATION
ACADEMIC FACULTY*
If you are currently an academic staff (teaching or non-teaching position), please check the following. If you do not have
NIDN/NUPN, please provide an SK PNS or SK Rektor.
☐ Permanent Teaching Staff NIDN/NUPN No. (circle one)
☐ Non-permanent Teaching Staff
☐ Research Staff
☐ Administrative Staff
☐ Other: Click or tap here to enter text.
* Applicants who are university lecturers and hold an NIDN should apply to the DIKTI-Funded Fulbright Grants for Indonesian
Lecturers program, using the application form for that program. See AMINEF website at https://www.aminef.or.id/grants-for-
indonesians/dikti-funded-Fulbright-Grants-for-Indonesian-Lecturers-PhD for further information and downloadable preliminary
application form.
CURRICULUM VITAE/RESUME
Please attach your CV/resume separately, do not exceed four (4) pages.
The CV/resume describes your academic credentials and demonstrates a record of scholarly achievements. When composing a
CV/resume, it is important to include, in reverse chronological order for each category:
 Education (universities attended, degrees earned and dates received)
 Professional positions held
 Courses taught and other services provided to students and the home institution
 Publications (provide full citations and list them starting with the most recent)
 Other professional activities, such as workshops, seminars and consultations
 Membership and activities in professional associations
 Professional honors, awards and fellowships
 Community service
ACADEMIC BACKGROUND
List all post-secondary educational institutions you have attended in reverse chronological order, including any in which you
may be presently enrolled.
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Institution 1 Click or tap here to enter text.

:
Level of Study Click or tap here to enter text.
:
Country Click or tap here to enter text.
:
City Click or tap here to enter text.
:
Name of Diploma or Degree Click or tap here to enter text.
Equivalent (e.g. BA/MA/MFA):
Actual Name of Degree or Click or tap here to enter text.
Diploma
:
Discipline Click or tap here to enter text.
:
Enrolled From Click or tap to enter a date.
:
Enrolled To Click or tap to enter a date.
:
Date Degree Received : Click or tap to enter a date.
If a degree is in progress, list expected date of conferral for Date Degree Received.

:
:
:
:
Diploma
:
:
:
:
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:
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:
Diploma
:
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:
:
PROFESSIONAL EXPERIENCES
List your work experience since university graduation. Start with the most current one.
Work 1
Current Role Click or tap here to enter text.
:
Position Title Click or tap here to enter text.
:
Employer Name (Institution) Click or tap here to enter text.
:
Start Date Click or tap to enter a date.
:
End Date Click or tap to enter a date.
:
If you are currently employed, please leave the End Date field blank
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Street Address Click or tap here to enter text.

:
:
State/Province Click or tap here to enter text.
:
Postal Code Click or tap here to enter text.
:
:
Work 2
:
:
:
:
:
:
:
:
:
:
Work 3
:
:
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:
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AWARDS AND RECOGNITIONS

Scholarship and Fellowship
List scholarships and/or fellowships you currently or previously received (other than previous Fulbright awards). Include the
source or sponsor, amount, where held, and duration.
1.
2.
3.
Have you previously been awarded a Fulbright grant?

☐ Yes ☐ No
If you have previously been awarded a Fulbright grant, please list the grant(s) below.
Award Type/Name : Click or tap here to enter text.
Previous Grant Year : Click or tap here to enter text.
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Award Type/Name : Click or tap here to enter text.

Previous Grant Year : Click or tap here to enter text.
Academic Honors and Prizes

List any academic honors and prizes you have received. Include any titles/and or dates.
1.
2.
3.
Published Books, Articles, and/or Theses

On a separate sheet of paper, provide a bibliography of your written, published work, such as journal articles, books, as well as
any unpublished theses (S1 or S2 skripsi), with full bibliographic citation. If the title is in Indonesian, provide a translation into
English in parentheses.
In addition, on one to two separate sheets maximum, please provide a sample of your academic writing in your proposed field of
study. This can be a translation from Indonesian.
1. Click or tap here to enter text.
Teaching Experience
Include any current or previous teaching positions
1.
2.
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3.
Research
Include any research you have completed in which you are currently involved.
1.
2.
3.
EXPERIENCE ABROAD
If you have traveled, lived, or studied in any country other than your own for more than a month, please list this experience
below. This can include time overseas for education, research, business, vacation, etc․
Country 1 Click or tap here to enter text.
:
:
:
Purpose of Travel Abroad Click or tap here to enter text.
:

:
:
:
:

:
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:
:
:
Have you recently entered the United States on a J-1 or J-2 visa?
☐ Yes ☐ No
If YES, please select the J category of sponsorship.
☐ Au Pair ☐ International Visitor ☐ Short-Term Scholar
☐ Camp Counselor ☐ Physician ☐ Specialist
☐ College and University Student ☐ Professor ☐ Summer Work Travel
☐ Government Visitor ☐ Research Scholar ☐ Teacher
☐ Intern ☐ Secondary School Student ☐ Trainee
LANGUAGE SKILLS
ENGLISH LANGUAGE PROFICIENCY

Please rate your English language proficiency as Native, Advanced, Intermediate, Beginner or No Ability in three categories
below.
Reading: Choose an item.
Writing : Choose an item.
Speaking : Choose an item.
ADDITIONAL LANGUAGE SKILLS

Please list any additional languages that may be of use for your project or study plans. Rate your proficiency as Native,
Advanced, Intermediate, Beginner or No Ability.
Language : Click or tap here to enter text.
Reading: Choose an item.
Writing : Choose an item.
Speaking : Choose an item.
TEST SCORES
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Attach a photocopy of each test result. Test results should not be older than 2 years.
Test Score Test Date (dd/mm/yy) Location
TOEFL
☐ Internet-Based (iBT) Click or tap here to Click or tap to enter a Click or tap here to enter
enter text. date. text.
☐ Institutional (ITP) Click or tap here to Click or tap to enter a Click or tap here to enter
IELTS Click or tap here to Click or tap to enter a Click or tap here to enter
GMAT Click or tap here to Click or tap to enter a Click or tap here to enter
GRE Click or tap here to Click or tap to enter a Click or tap here to enter
GRE Subject Click or tap here to Click or tap to enter a Click or tap here to enter
OTHER Click or tap here to Click or tap to enter a Click or tap here to enter
While it is not required at the time of preliminary application, candidates must eventually take the Graduate Record Examination
(GRE) for all fields except law and business, or the Graduate Management Admission Test (GMAT) for business administration,
finance, or accounting. It is recommended that applicants begin to familiarize themselves with the relevant tests.
STUDY PLAN
PROPOSED PROGRAM LEVEL

Check appropriate box
DOCTORAL DEGREE (PHD) PROGRAM

☐ FULBRIGHT DOCTORAL DEGREE (PHD) PROGRAM
MASTER’S DEGREE PROGRAM
☐ FULBRIGHT MASTER’S DEGREE (MA/MS) PROGRAM
PROPOSED FIELD OF STUDY AND FUTURE PLANS

The proposed field of study should be appropriate to your academic background or professional experience. Be specific. (i.e.
Major Field of Study: Geography, Specialization/Sub-field: Cartography and Land Mapping).
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Major Field of Study : Click or tap here to enter text.

Specialization/Sub-field : Click or tap here to enter text.
Briefly describe proposed field of study in which you plan to specialize in the United States (Max: 150 words and 1100
characters)
Briefly describe your future plans upon completion of study in the United States (Max: 150 words and 1100 characters)
PLAGIARISM AGREEMENT
The Fulbright Program seeks applicants who have developed a sense of personal integrity and are original thinkers. The
following application includes several opportunities to express your own thoughts, ideas, and opinions in essay
responses. Plagiarism in any of your answers to these questions will result in your disqualification from participating in
the program.
From the Oxford English Dictionary:
"Plagiarism is the wrongful appropriation or purloining and publication as one's own, of the ideas, or the expression of the
ideas of another."
Plagiarism will be understood to include any of the following:
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Presenting wording, statistics or concepts as your own which should be attributed to someone else or to publications (online or
offline). This includes, but is not limited to:
 Copying the exact wording of a written source

 Presenting material with alterations in wording
 Paraphrasing the content of a source without citation
It is expected that your responses to essay questions in the application will be your own work, and that use of outside sources
will be kept to a minimum. Applicants do not have to use secondary sources for essays. However, any sources used in the
construction of your responses must be cited.
By indicating 'Yes' in the question below, you are acknowledging that you understand both what actions constitute plagiarism in
this application, and the consequences resulting from any plagiarism found in your submission.
I have reviewed and understand the above information on the importance of presenting my own original work in the Fulbright
Program application. I agree to properly cite any outside sources from which I take words or ideas in the composition of my
essay responses. I understand any falsification or plagiarism found in my Fulbright application will result in my dismissal from
the Fulbright Program.
☐ Yes
☐ No
STUDY OBJECTIVES
On a separate sheet of paper, or a separate document in PDF format, provide a clear and detailed description of your study
objectives and your reasons for wanting to pursue them. (Do not exceed one page single-spaced.) Be specific about your major
field and your specialized interests within this field․ Describe the kind of program you expect to undertake, and explain how
your study plan fits in with your previous training and your future objectives․ For PhD students, if you already have an idea of
the kind of original research project you wish to pursue, very briefly describe it; however, since PhD study requires coursework,
comprehensive exams, and thesis proposal defense before proceeding to any PhD research, this is not the place to talk too
specifically or at length about that research. Here you should just mention any research interests. This statement is an essential
part of your application and is required․ Do not mention specific U․S․ universities at which you would like to study.
PERSONAL STATEMENT
On a separate sheet of paper, or a separate document in PDF format, provide a narrative statement describing how you have
achieved your current goals. (Do not exceed one page single-spaced.) It should not be a mere listing of facts․ It should include
information about your education, practical experience, special interests, and career plans․ Describe any significant factors that
have influenced your educational or professional development․ Comment on the number of years of practical experience already
completed in the field in which academic work will be done in the U․S․ Do not mention specific U․S․ universities at which you
would like to study․
UNIVERSITY PREFERENCES
It is not a requirement nor is it expected for you to identify institutions at which you would like to study․ However, if you do
have preferences, please list in priority order up to four schools of your choice․ Indicate specific departments and/or programs․
Give specific reasons for each choice․ If you have been in contact with professors, please provide names and e-mail and/or
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phone contacts for each one․ Your preferences will be taken into consideration insofar as possible․ However, please understand
that there is no guarantee that your application will be sent to these programs․ Applications are made on your behalf to programs
that provide a good “academic fit” based on your study plans and your competitiveness․ The goals and priorities of your
scholarship sponsor are also strongly considered․
Institution Name 1 : Click or tap here to enter text.

Department : Click or tap here to enter text.
Degree : Click or tap here to enter text.
Specialization/Concentration : Click or tap here to enter text.
Contacts : Click or tap here to enter text.
Specific Reasons :

Specific Reasons :

Specific Reasons :

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Specific Reasons :
U.S INSTITUTIONS APPLIED TO

If you are intending to or have already started to apply to a U.S. university, please provide the name of the university you have
applied to. Note that a letter of admission is not required for the Fulbright Visiting Student program prior to application
submission.
Date Applied : Click or tap to enter a date.
Name of contact : Click or tap here to enter text.
Status : Click or tap here to enter text.

Name of contact : Click or tap here to enter text.
SOCIAL AND COMMUNITY INVOLVEMENT
If you have been involved in local community organizations, or philanthropic organizations, or professional or fraternal
organizations, list them below as proof of your social and community involvement. Indicate any leadership role you have
exercised.
Location : Click or tap here to enter text.
Date : From Click or tap to enter a date. To Click or tap to enter a date.
Position : Click or tap here to enter text.
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Responsibility :

Date : From Click or tap to enter a date. To Click or tap to enter a date.
Responsibility :

Date From/To : From Click or tap to enter a date. To Click or tap to enter a date.
Responsibility :
RECOMMENDATIONS
List the two persons from whom you have requested a letter of reference. This letter of reference must be written by a
teacher/lecturer under whom the applicant has studied in the proposed field of study or by someone who has supervised the
applicant in work related to the proposed field of study. This letter must be in English. If not in English, then an accurate
translation must be forwarded to the Fulbright Program Office. A specific format and instruction for this letter is available at
AMINEF website.
The letter must describe the applicant's qualifications and potential for successfully completing further academic study in
the U.S, including:
 Applicant's outstanding talents
 How he or she compares with peers, both academically or in leadership roles
 Observation on the applicant's character
 Other comments or relevant insights that you can offer that are not likely available from other sources.
Recommender 1
First Name : Click or tap here to enter text.
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Last Name : Click or tap here to enter text.

Institution : Click or tap here to enter text.
Position/Title : Click or tap here to enter text.
Relationship : Click or tap here to enter text.
Telephone : Click or tap here to enter text.
Recommender 2
First Name : Click or tap here to enter text.
Last Name : Click or tap here to enter text.
Institution : Click or tap here to enter text.
Position/Title : Click or tap here to enter text.
Relationship : Click or tap here to enter text.
Telephone : Click or tap here to enter text.
OTHER SCHOLARSHIPS
If you are currently applying for another scholarship program, or if you have already been offered another scholarship, list the
program and status of your application. (This includes other Fulbright or AMINEF-administered scholarship or fellowship
programs.) Be specific.
Name of Scholarship : Click or tap here to enter text.

Sponsor/Facilitator : Click or tap here to enter text.
Program Level : Click or tap here to enter text.
Date Received : Click or tap to enter a date.
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OUTREACH SURVEY
How did you learn about Fulbright program.

☐ Friends/Relatives ☐ Fulbright Alumnus ☐ Poster/Flyer ☐ University ☐ Newspaper
☐ Other publication ☐ AMINEF Website ☐ Other website ☐ Social Media ☐ U.S. Embassy
☐ Other Click or tap here to enter text.
How long did you consider applying for the Fulbright Foreign Student award before submitting this application? (please put the
number of years)
Click or tap here to enter text. years
What were the major factors in helping you decide to apply for a Fulbright award?
☐ Reputation of the Fulbright Program
☐ Publicity about the program
☐ Advice of a colleague
☐ Advice of a former Fulbrighter
☐ Time was right in my career
☐ Other
Please describe:
Have you participated in any of the U.S. Government sponsored programs listed below?
☐ English Access Micro Scholarship
☐ Global Undergraduate Scholarship (UGRAD)
☐ Kennedy-Lugar Youth Exchange & Study Program (YES)
☐ Future Leaders Exchange Program (FLEX)
☐ Study of the U.S. Summer Institute
☐ Summer Institute for Young Leaders
☐ Muskie Fellowship
☐ Humphrey Fellowship
☐ Undergraduate Intensive English Language Scholarship
☐ Timor or South Pacific Scholarship
☐ Community College Initiative (CCI) Program
☐ Other
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Please describe:
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DECLARATION
 I hereby certify that the information I have provided on this application form and in any attached materials is accurate,
complete and true to the best of my knowledge and belief, and I agree to notify AMINEF of any change in the above
information or of any further information that might affect my eligibility for consideration as a prospective recipient of
the Fulbright Scholarship award.
 I understand that by completing this application form there is no assurance that I will be awarded a grant.
 I understand that the scholarship offered is for the chosen and approved field and level of study program and I will not
change my enrollment without consent from AMINEF and its cooperatives.
 I understand that no additional grant or study will be considered under this scholarship.
 I understand I will meet all the course requirements of the US education institution based on the approved length of the
grant awarded.
 I understand I am not permitted to engage in employment beyond the J visa restriction and without consent from
AMINEF and its cooperatives.
 I understand that I will return home upon the completion of my study as per J visa policy of the Two-Year Home Country
Residence Requirement.
 I understand that I will not be eligible to continue my Fulbright selection process if I am accepting another scholarship
program.
 I understand that grant funds are not sufficient to cover travel or support for my family and I will make necessary
arrangements for the living expenses in Indonesia while I am away or in the U.S. if they wish to join me.
 I have no objection to publicity about my selection for a Fulbright Scholarship.
Signature: Date: _____________________________________________
The Fulbright Program was initiated in Indonesia in 1952. Since then, thousands of scholars from Indonesia, including key
figures in the governmental, private and cultural sectors, have traveled and successfully studied for an advanced degree in the
United States. Since 1992, the American Indonesian Exchange Foundation (AMINEF) has been managing the Fulbright
Program in Indonesia as one of 50 binational Fulbright Commissions around the world. AMINEF was established in 1987 to
bring a higher level of cooperation and local involvement to the Fulbright Program. AMINEF runs an open, merit-based
competition for Fulbright grants. Applications are reviewed by AMINEF selection team. Those applicants who meet the
minimum standards of the program are then interviewed by a binational selection committee that includes experts from their
fields. The recommendations of the selection committee are reviewed by the AMINEF Board’s Educational Exchange
Committee. The resultant list of nominees is then sent to the J. William Fulbright Foreign Scholarships Board in Washington,
D.C., for final approval.
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RETURN THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTS TO:
AMERICAN INDONESIAN EXCHANGE FOUNDATION (AMINEF)

Intiland Tower, 11th Floor
Jl. Jend. Sudirman 32
Jakarta 10220
APPLICATION CAN BE RETRIEVED FROM:
www.aminef.or.id
FOR ANY INQUIRIES:
Ph. (021) 5793-9085/86

Fax. (021) 5793-9089
E-mail: infofulbright_ind@aminef.or.id
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CHECK LIST
Please check if you have attached the following documents in support of your application
NO REQUIRED ITEMS DESCRIPTION COMPLETED

1. Application Complete application form, please type, do not write
2. Study objective One-page essay. See the application pg. 13 for details
3. Personal statement One-page essay. See the application pg. 13 for details
4. A bibliography of your written, Provide journal articles, books, as well as any unpublished theses
published work (S1 or S2 skripsi), with full bibliographic citation and translated
into English.
5. An academic writing sample One to two pages of your writing related to the chosen field of
study and translated into English.
6. Original letters of reference Obtain two (2) from your supervisor, lecturer, or professor who
knows you well. You may send the letter in a sealed envelope
along with your application or have the persons who give you the
reference send it directly to AMINEF. Use the Fulbright
reference form available for download in the AMINEF website
7. Copy of academic transcripts* Certified copies of your academic records for all post-secondary
institutions attended; must list courses taken and grades received
for each year of enrollment
8. Original translation of If your official transcript(s) are not issued in English, have
academic transcripts official transcripts translated into English: must be literal, not
interpretative
9. Copy of diploma(s)* Certified copies of your diploma(s) for all post-secondary
institutions attended in original language
10. Original translation of If your diploma(s) are not issued in English, have diploma(s)
diploma(s) translated into English: must be literal, not interpretative
11. Copy of standardized tests Copy of most recent, less than 2 years old test result
TOEFL/IELTS*
12. Copy of national ID Copy of both or either one and the ID (KTP)/passport is still
(KTP)/Passport* valid
13. Copy of letter of appointment Copy of SK which includes rights and obligations from the
for faculty member (SK university and signed by the Rector of the university or chairman
Pengangkatan or PNS) * of the foundation
14. Curriculum Vitae Provide the current one. See the application pg. 4 for details.
* Do not attach original documents, only certified copies.
THIS FORM IS TO BE FILLED OUT COMPLETELY AND ACCURATELY.

WE REGRET INCOMPLETE APPLICATION WILL NOT BE CONSIDERED.
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FULBRIGHT VISITING

NAME ON PREVIOUS RECORD

EMERGENCY CONTACT INFORMATION

ACADEMIC & PROFESSIONAL INFORMATION

Institution 1 Click or tap here to enter text.

Institution 2 Click or tap here to enter text.

Date Degree Received : Click or tap to enter a date.

Institution 3 Click or tap here to enter text.

Street Address Click or tap here to enter text.

Employer Name (Institution) Click or tap here to enter text.

AWARDS AND RECOGNITIONS

Have you previously been awarded a Fulbright grant?

Award Type/Name : Click or tap here to enter text.

Academic Honors and Prizes

Published Books, Articles, and/or Theses

Country 2 Click or tap here to enter text.

Country 3 Click or tap here to enter text.

Start Date Click or tap to enter a date.

ENGLISH LANGUAGE PROFICIENCY

ADDITIONAL LANGUAGE SKILLS

PROPOSED PROGRAM LEVEL

DOCTORAL DEGREE (PHD) PROGRAM

PROPOSED FIELD OF STUDY AND FUTURE PLANS

Major Field of Study : Click or tap here to enter text.

From the Oxford English Dictionary:

Plagiarism will be understood to include any of the following:

 Copying the exact wording of a written source

Institution Name 1 : Click or tap here to enter text.

Institution Name 2 : Click or tap here to enter text.

Institution Name 3 : Click or tap here to enter text.

Institution Name 4 : Click or tap here to enter text.

Specialization/Concentration : Click or tap here to enter text.

U.S INSTITUTIONS APPLIED TO

Institution Name 2 : Click or tap here to enter text.

SOCIAL AND COMMUNITY INVOLVEMENT

Institution Name 2 : Click or tap here to enter text.

Institution Name 3 : Click or tap here to enter text.

Last Name : Click or tap here to enter text.

Name of Scholarship : Click or tap here to enter text.

Name of Scholarship : Click or tap here to enter text.

Sponsor/Facilitator : Click or tap here to enter text.

Name of Scholarship : Click or tap here to enter text.

How did you learn about Fulbright program.

Signature: Date: _____________________________________________

RETURN THE COMPLETED APPLICATION AND SUPPORTING DOCUMENTS TO:

AMERICAN INDONESIAN EXCHANGE FOUNDATION (AMINEF)

APPLICATION CAN BE RETRIEVED FROM:

FOR ANY INQUIRIES:

Ph. (021) 5793-9085/86

NO REQUIRED ITEMS DESCRIPTION COMPLETED

* Do not attach original documents, only certified copies.

THIS FORM IS TO BE FILLED OUT COMPLETELY AND ACCURATELY.

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