New Zealand Head of Embassy Fund

Opening Round for Financial Year 2022/2023

Application Form and Information for Applicants
PURPOSE

The Fund supports small scale, short-term community projects that contribute to wider community well-being.
The projects must be in line with New Zealand Aid Programme’s mission of:

Sustainable development in developing countries, in order to reduce poverty and contribute to a

more secure, equitable and prosperous world.
WHO

The Fund is aimed primarily at community groups and NGOs but other types of organisations e.g. schools,
business associations may apply. The Fund does not support individual businesses.

HOW LONG

No individual project will be supported for longer than two years. Supporting different projects by the same
partner over a longer duration is possible.

WHAT WILL NOT BE FUNDED

 political, religious or evangelical activities N.B. faith-based groups are not excluded where the
proposed project is consistent with the purpose of the Fund, does not exclude followers of other
religions, and the funds are not used to support proselytising
 site visits
 unsolicited donations
 individual student scholarships
 international airfares/overseas conference attendance
 on-going (recurrent) funding of recipients’ operational/organisational costs such as wages and
salaries, office items and communications

APPLICANT PROCESS

 For further information and to send your application by email the New Zealand Embassy contact
monica.vasquez@mfat.govt.nz
 Applications for the opening round of FY 2022/2023 close at 4.00 pm on 20 December 2022.
 Applicants are encouraged to apply as soon as possible.

5
 Please ensure you have read our criteria thoroughly before submitting an application. As resources
are limited we will prioritise those activities that best meet the HEF criteria.
 If the application is incomplete your application may not be considered. If further information is
required it will delay the decision-making process.
 We may need to contact you about your application usually by email.
 Once decisions have been made, all applicants will be notified by email. Please allow up to 2 months
from the application closing date to receive a notification regarding the final decision

6
A. INFORMATION ABOUT THE APPLICANT ORGANISATION

(INFORMASI TENTANG ORGANISASI PEMOHON)

This column to be filled in by the applicant.

(Kolom yang harus diisi oleh pemohon)

Name of organisation: Bakrie University/Universitas Bakrie

Nama organisasi

Legal status : Keputusan Hukum dan Hak Asasi Manusia Republik

Status resmi Indonesia
(Attach notarial act) Nomor : AHU 3208.AH.01.05.Tahun 2008
(Lampirkan akta notaris)
Street/Jalan: Kawasan Rasuna Epicentrum, Jl. H. R. Rasuna Said No.2,
RT.2/RW.5

Address – Alamat lengkap: Village/Desa: Karet, Kecamatan Setiabudi

Region/Kabupaten: Kota Administrasi Jakarta Selatan

Province /Propinsi: DKI Jakarta

Postal Code/Kodepos: 12940

Contact Name for this application: Mohammad Ihsan
Nama kontak untuk aplikasi ini

Phone number – No. Telepon 081511732183

Fax number – Nomor fax 021-5261448

Email address – Alamat email mohammad.ihsan@bakrie.ac.id

Bank Account Information: Mandiri

No. Rekening : 900-00-2458351-1
Informasi rekening bank organisasi Anda
Atas Nama : Mohammad Ihsan
References: Lembaga Teknologi Fakultas Teknik Universitas Indonesia
Referensi http://www.lemtek-ui.com
Retyaning Puji Utami,
Please provide two reachable referees retyaning@gmail.com retyaning@lemtek-ui.com
that your institution had worked before +6281311448440
and/or your institution received funding.
(Beneficiaries should not stand as a School of Quantity Surveying Indonesia
referee). https://sqsindonesia.com
Eliyanti
Cantumkan 2 pemberi referensi yang organisasi +628128819572
Anda pernah bekerja sama sebelumya dan/atau
pemberi referensi dari pihak donor yang mendanai
kegiatan organisasi Anda (Pihak penerima manfaat
tidak termasuk kategori penulis referensi)
The position, organization, and contact
information of the referee must be
mentioned clearly.
Jabatan, organisasi, dan kontak informasi dari
penulis referensi harus disebutkan dengan jelas

7
B. INFORMATION ABOUT THE PROJECT
(INFORMASI TENTANG PROYEK)
Project Title:
(Judul proyek)
Project Location:
(Lokasi proyek)
Starting date of project:
(Tanggal proyek mulai)
Completion date of project:
(Tanggal proyek selesai)
Describe the Project.
(Why the project is urgent? What problem
does the project want to address? If your
project involves small construction work,
please provide a simple project design with causes the intensity of damage to buildings to be quite high.
material cost calculations for the various Therefore, it is necessary to have a vibration detection system on
components of the whole project on a
separate sheet.)
(Mengapa proyek ini mendesak? Bagaimana and alert with large vibrations that may occur in a few seconds.
proyek yang anda ajukan membantu
menyelesaikan persoalan yang ada? Jika
proyek anda melibatkan pekerjaan
konstruksi, berikan desain proyek sederhana
dengan perhitungan biaya bahan untuk
berbagai komponen dari keseluruhan proyek
pada lembar terpisah)
How does the Project support
vulnerable populations, lives, and
livelihoods impacted by COVID-19?
(Bagaimana proyek ini mendukung
kelompok yang paling membutuhkan,
kehidupan dan mata pencaharian
masyarakat yang terdampak COVID-19?)
Who did your group consult with
Early Warning System with Small-Scale Vibration Detection Tool
as Mitigation of Earthquake Disasters, Especially in the Cimandiri
Fault Area and Training Earthquake Mitigation
Cianjur Regency, West Java, and the surrounding regencies which
are in the Cimandiri fault point (Pelabuhan Ratu, Sukabumi
Regency, then heading northeast past Cianjur Regency, West
Bandung Regency, and Subang Regency).
9 Maret 2023
1 Mei 2024
The characteristics of earthquakes caused by fault movements
are quite dangerous because small movements can cause quite
large vibrations on the surface of the ground or earth which
the soil slab below the soil surface, where when a shift occurs in
the soil layer, the detector gives a notification signal to be careful
then.
Here's the project design:
The tool in this project provides a notification signal to be careful
and alert for large earthquake vibrations that may occur a few
seconds later, so that as a disaster mitigation effort in an area,
especially in the main point of the Cimandiri fault line which is
one of the causes of earthquake disasters on November 21, 2022
in Cianjur, West Java.
Lembaga Teknologi Fakultas Teknik Universitas Indonesia
8
when developing the idea for this
project?
(Siapa yang dikonsultasikan ketika anda/Tim
mengembangkan ide untuk proyek ini?)
http://www.lemtek-ui.com
Fieneshia Sevita
fieneshiasevita@gmail.com
fieneshia.sevita @lemtek-ui.com

What are the project’s objectives?
(Apa tujuan proyek?)
What do you want to achieve?
(Apa yang hendak dicapai?)
Who will benefit from the project
and how will they benefit? (include
no. of women, men, boys and girls)
(Siapa yang akan mendapatkan manfaat
dari proyek dan bagaimana mereka akan
mendapatkan manfaat? termasuk jumlah
perempuan, anak laki-laki dan anak
perempuan)
Once the activity is completed who
will take responsibility for future
costs and maintenance?
(Setelah kegiatan selesai, siapa yang akan
mengambil tanggung jawab untuk biaya di
masa depan dan pemeliharaan?)
+62 813-7980-3111
Disaster mitigation efforts to reduce the risk and impact of
natural disasters, especially earthquakes by monitoring ground
movement at speeds that will be read by the Accelerometer
sensor and giving warnings to local residents in the form of
warning alarms.
In this project, the people who are at the point of the Cimandiri
fault line will benefit, namely nine villages in the Cianjur region,
West Java, namely 6 villages in Cugenang District consisting of
Cibeureum Village, Nyalindung Village, Mangunkerta Village,
Sarampad Village, Cibulakan Village, and Benjot Village and 2
villages in Pacet District, namely Ciherang Village, Ciputri Village
and also one other village at the end of the fault, namely Nagrak
Village, Cianjur District.
After the activity is completed, the one who will take
responsibility for future maintenance and operations is an
earthquake disaster mitigation community under the applicant's
organization.

Describe how you will monitor By supervising each stage of work and conducting performance
progress towards outcomes and evaluations by distributing evaluation forms to the public and
evaluate the success of the Project related parties.
(Jelaskan bagaimana anda akan memonitor
progres terhadap hasil/capaian proyek dan
bagaiaman anda akan mengevaluasi
keberhasilan proyek tersebut)
How much do you want for this 249.900.000 IDR
project?
(Berapa banyak dana yang anda butuhkan
untuk proyek ini?)

Has your group applied to this Fund No Yes

previously?
(Apakah organisasi Anda pernah
mengajukan dana ini sebelumnya?)

If yes, please provide details of the

funding request and the year the
request was made.
(Jika ya, silakan berikan rincian permintaan
dana dan tahun permintaan itu dibuat.)

Have you requested assistance

from any other source for this No Yes
project?
(Apakah anda meminta bantuan dari sumber
lainnya untuk proyek ini?)
If yes, please describe:
(jika iya, jelaskan)

9
Was the funding requested above
successful? If not why not? Yes, the funding requested above successful
(Apakah dana yang dimintakan diatas
sukses? Jika tidak, jelaskan)

What will your group contribute To develope equtment for eary warning sistem fo qaerthquqke in
towards the achieving project? falut zone. ( Sesar Cimandiri). To traine local comunity for using ,
(Apa kontribusi organisasi anda untuk mainteneing and sleft warning, lifing in zone fault
keberhasilan proyek?)

Implementation Plan (Show key tasks)

Rencana implementasi (Tampilkan tugas-tugas utama)
Start Date End Date Task Inputs required
(Tanggal mulai) (Tanggal akhir) (Tugas) (Input yang diperlukan)
09/03/2023 09/03/2023 Kick Off meeting All Member Team, Meeting room,
Meeting Full Board (12 Personnel)
10/03/2023 31/03/2023 Production off Sensor and Technical member (5 Personnel),
equipment Material production
03/04/2023 05/04/2023 Delivered Material and Technical member (5 Personnel), Local
Equipment labour, Transportation
06/04/2023 11/04/2023 Install Sensor and Equipment Technical member (5 Personnel), Local
labour, Material installation
12/04/2023 12/04/2023 Evaluation and testing All Member Team, Meeting room,
Meeting Full Board (12 Personnel)
13/04/2023 15/04/2023 Training Using Equipment Technical member (5 Personnel),Local
community, Meeting Full Board (15)
16/04/2023 17/04/2023 Training Maintenance Equipment Technical member (5 Personnel ),Local
community, Meeting Full Board (3
Personnel )
01/05/2023 01/05/2024 Maintenance Equipment Local Member ( 3 Personnel)

C.MANAGEMENT OF THE PROJECT

(MANAJEMEN PROYEK)

The organisation
What’s the objective of Vision
the organisation? A globally recognized university through engagement with industries and
(Apakah tujuan dari organisasi?) experiential learning methods.

Length of time in
existence:
(Sudah berapa lama organisasi
berdiri dan beroperasi)
History of your activities
Mission
- To provide high quality education in a competitive society
through practice and experiential learning methods.
- To produce graduates with entrepreneurial values and leadership
skills for delivering innovative solutions in a global competitive
environment.
- To advance knowledge, skills and integrity among professionals
and leaders.
To establish productive and enduring engagements with industries in
teaching, research and community service.
Since 2009

10
and funding
(Sejarah kegiatan Anda dan
pendanaan)
Who will manage the project (e.g. Project Coordinator) and provide financial report on expenditure?
(Siapa yang akan mengelola proyek (misalnya koordinator proyek) dan memberikan laporan keuangan pada pengeluaran?)
Name:
(Nama)
Qualification/Skills of the
Project Coordinator
(Kualifikasi/keterampilan
koordinator proyek)
Experience of the Project
Coordinator
(Pengalaman koordinator
proyek)
Dr. Mohammad Ihsan A.Md., S.T., M.T., M.Sc
- Technical skill of make equipment and sensor
- Management skill in project Investigation
Name of Project Location Owner
Structure Investigation, Extension life
PT. Citra Marga
Jakarta
service, Tol Ir Wiyoto Wiyono Nusaphala Persada.
Structure InvestigationTerminal 2E, PT.
Jakarta PT. Angkasa Pura 2.
Angkasa Pura 2.
Structure Investigation and design
strengthening runwaysnorth,
Jakarta PT. Angkasa Pura 2.
Extension life service, PT Angkasa Pura
2.
Structure Investigation and design
strengthening taxiwayssouth,
Jakarta PT. Angkasa Pura 2.
Extension life service,PT Angkasa Pura
2.
Design Facility Soekarno Hatta
International Airport , PT Angkasa Pura Jakarta PT. Angkasa Pura 2.
2.
Structure Investigation Due Diligence,
Wisma Mandiri 1 dan 2, PT. Bank Jakarta PT. Bank Mandiri.
Mandiri.
Structure Investigation Due Diligence
Jakarta PT. Bank Mandiri.
Menara Mandiri 2, PT. Bank Mandiri.
Structure Investigation Due Diligence
Jakarta PT. Bank Mandiri.
Graha Mandiri, PT. Bank Mandiri.
Structure Investigation Due Diligence
Jakarta PT. Bank Mandiri.
Dana Graha, PT. Bank Mandiri.
Structure Investigation Due Diligence
Jakarta PT Red Top.
Red Top, PT Red Top.
Structure Investigation HO Indonesia PT, Indonesia Power.
Jakarta
Power, PT, Indonesia Power.
Structure Investigation heritage
Jakarta PT. Bank Mandiri.
building Gedung 5, PT. Bank Mandiri
Structure Investigation heritage
building Mandiri Medan, PT. Bank Jakarta PT. Bank Mandiri.
Mandiri.
Structure Investigation heritage
Medan PT. Bank Mandiri.
building Kali Besar, PT. Bank Mandiri.
Design Bridge and hall 3 4 Sport Universitas Indonesia.
Depok
Center, Universitas Indonesia.
Design strengthening Gedung Arsip. Universitas Indonesia.
Depok
Universitas Indonesia.
Design strengthening Fasilkom
Universitas Indonesia.
Universitas Indonesia. Universitas Depok
Indonesia.
11
Design strengthening RSKGM. Universitas Indonesia.
Jakarta
Universitas Indonesia.
Universitas Indonesia.
Design Facility, Universitas Indonesia. Depok
Design strengthening heritage building
Universitas Indonesia.
FKUI, Extension life service, Universitas Jakarta
Indonesia
Design rest area Cipali. Cipali
Structure Investigation and
strengthening HO Toyota , PT Jakarta PT TAMMIN.
TAMMIN.
Structure Investigation and
strengthening Office Toyota Karawang Karawang PT TAMMIN.
Plant, PT TAMMIN.
Structure Investigation BTN Sidoarjo Sidoarjo PT BTN
Structure Investigation Kantor
Cirebon Bank Indonesia
Perwakilan Bank Indonesia Cirebon
Structure Investigation Kantor
Bandung Bank Indonesia
Perwakilan Bank Indonesia Jawa Barat
Structure Investigation Kantor
Perwakilan Bank Indonesia Tasikmalaya Bank Indonesia
Tasikmalaya
Structure Investigation Aset Bangunan,
Jakarta LMAN
Lembaga Manajemen Aset Negara
Upgrading Gedung Lembaga
Jakarta LMAN
Manajemen Aset Negara
Structure Investigation Gedung Universitas Indonesia.
Depok
FASILKOM Universitas Indonesia
Sructure Investigation Gedung Engine
Jakarta PT TAMMIN.
7K Sunter 1 PT TAMMIN.
PT BNI
Design strengthening PLAZA BNI BSD. Serpong
Third party review technical
aspect,MRT Jakarta Phase 1. PT MRT Jakarta PT MRT Jakarta
Jakarta
Acceleration claim in construction
AirportAhmad Yani Semarang, PT. Semarang PT. Waskita Karya
Waskita Karya
Claim in construction Tol Jakarta
Jakarta PT. Waskita Karya
Cikampek 2, PT. Waskita Karya
Claim in construction Tol Becakayu, PT.
Jakarta PT. Waskita Karya
Waskita Karya Becakayu
Due diligence technical Tol Ruas PT. Cibitung Tanjung
Cibitung - Cilincing. PT. Cibitung Jakarta Priok Port Tollways
Tanjung Priok Port Tollways
Due diligence technical Tol Ruas Kanci PT. Semesta Marga
Cirebon
- Pejagan PT. Semesta Marga Raya Raya
Due diligence technical Tol Ruas PT Pejagan Pemalang
Pejagan–Pemalang PT Pejagan Tegal Tol Road (PPTR)
Pemalang Tol Road (PPTR)
Due diligence technical Tol Ruas PT Trans Jawa Paspro
Probolinggo
Pasuruan–Probolinggo PT Trans Jawa Jalan Tol (TPJT)

12

Who else will be involved in the delivery of the project?
(Siapa lagi yang akan terlibat dalam pelaksanaan proyek?)
Name
(Nama)
Prof. Ir. Sofia W.
Alisjahbana, M.Sc.,
Ph.D., IPU
Dr. Ir. Budianto
Ontowirjo, M.Sc
Fatin Adriati, S.T., M.T.
Dr. Ir. Ade Asmi, S.T.,
M.Sc., IPM, ASEAN Eng.
Safrilah, S.T., M.Sc.
Vania Claudia, S.Pd
Esa Hoirunisa, S.T
Dhebi Tri Astuti, S.T
Vidia Pratiwi, S.T
Muhammad Thalman
Harsha
Muhammad Al Faruq
PROJECT BUDGET SUMMARY
(RINGKASAN ANGGARAN PROYEK)
Paspro Jalan Tol (TPJT)
Review Structure, Elia Skin Care Clinic,
Tanggerang
Tanggerang
Role Experience in relation to delivering the project
(Jabatan) (Pengalaman dalam kaitannya dengan memberikan
proyek)
Rector of Bakrie Technical skill of dinamics load
University
Lecturer of Civil Technical skill of make equipment and sensor
Engineering, Bakrie
University
Lecturer of Civil Technical skill of soil characteristic
Engineering, Bakrie
University
Lecturer of Civil Management skill in project Investigation
Engineering, Bakrie
University
Lecturer of Civil Technical skill of make equipment and sensor
Engineering, Bakrie
University
Education program Non-governmental organization
division, Bakrie Amanah
Civil Engineering, Bakrie Assistant
University
Civil Engineering, Bakrie Assistant
University
Civil Engineering, Bakrie Assistant
University
Civil Engineering, Bakrie Assistant
University
Civil Engineering, Bakrie Assistant
University
13
 Fund Your Other Contributors Total Cost
Contributions* Contribution (Dana dari kontributor (Biaya total)
(Dana yang (Dana yang lain, jika ada)
diajukan ke dikontribusikan dari
New Zealand Aid organisasi Anda, jika
Programme) ada)
Labour Costs

Honorarium 36.000.000 - - 36.000.000

Travel 26.250.000 - - 26.250.000
Training Earthquake 17.500.000 - - 17.500.000
Material & Equipment
Install Equipment (5 42.500.000 - - 42.500.000
location)
Machinery 6.000.000 - 6.000.000
Freight 2.000.000 - 2.000.000
Consumables (fuel, 5.000.000 - - 5.000.000
fertiliser, chemicals)
Materials ( 5 set) 84.000.000 - - 84.000.000
Maintenance (2 years) 12.000.000 - 12.000.000
Overheads
Communications 5.000.000 - 5.000.000 -
Transport 9.450.000 - 9.450.000 -
Training Maintenance 4.200.000 4.200.000 -
TOTAL 249.900.000
225.700.000 24.200.000
IDR
* Attach invoices/purchase orders from suppliers for all items requested. You should include shipping costs as
part of the invoice/purchase order if possible.
* Lampirkan pesanan faktur pembelian dari pemasok untuk semua item yang diminta. Anda harus memasukkan biaya pengiriman sebagai
bagian dari faktur pembelian jika memungkinkan.

Risk Management
(Manajemen Risiko)

List the risks associated with delivery of the project, i.e. what might get in the way?
Please also detail how your group will manage the risk to ensure that the project will be delivered.
(Daftar risiko yang terkait dengan pelaksanaan proyek, seperti rintangan dalam pelaksanaan proyek?
Silahkan juga dirinci bagaimana organisasi mengelola risiko untuk memastikan berjalannya proyek)

Risk How will the risk be managed?

(RIsiko) (Bagaimana rIsiko akan diatasi?)
Health problems due to conditions Use of complete APD for Technical members and Local
in the field labour.
exposed to digging tools (hoes, Use of safety shoes and helmets during excavation and
balencong etc.) installation of tools
Hazards due to landslides of Slopes are strengthened first with the use of bamboo
excavation slopes waterfalls and the like.
Health and Safety
(Kesehatan dan Keamanan)

1. Are there any potential health and safety risks to workers or others during the implementation
phase of this project?

14
 (Apakah ada potensi risiko terhadap kesehatan dan keamanan pihak-pihak yang terlibat selama proses implementasi proyek ini?

Circle one: Yes No

(Lingkari salah satu)

If Yes – complete the following table. An example is provided in blue.

(Jika ya-lengkapi tabel di bawah ini. Sebagai contoh, lihat teks berwarna biru.)

What tasks will be done to
complete this project?
(Pekerjaan-pekerjaan apa yang
akan dilakukan untuk
menyelesaikan proyek ini?)
Providing & installing of
Sondir Iron Rods by project
workers
Providing & installing of
Accelerometer sensor
circuit to the main body
Providing & installing of
concrete slab casting work
What tasks could cause What will be done so that the injury does not
an injury? occur?
(Apa yang akan dilakukan untuk mencegah terjadinya
(Pekerjaan-pekerjaan apa yang
dapat menyebabkan kecelakaan kerja tersebut?)
kecelakaan kerja?)
- Risk of landslides of - Personal protective equipment is
excavation slopes provided to workers including safety
harnesses and Slopes are strengthened
- Risk of injury when first with the use of bamboo waterfalls
using tools and and the like.
machines - Installers are trained or qualified to carry
out the work
- Risk of electric shock - Personal protective equipment is
provided to workers including gloves
- Risk of injury when - Installers are trained or qualified to carry
using tools and out the work
machines

2. Will the outcome of this project be used by the general public? I.e. community projects or public
buildings/services.
(Apakah keluaran dari proyek ini akan digunakan oleh publik secara umum? Sebagai contoh, proyek komunitas atau
bangunan/pelayanan publik?

Circle one: Yes No

(Lingkari salah satu)

If Yes complete the following table. An example is provided in blue.

(Jika ya-lengkapi tabel di bawah ini. Sebuah contoh ditandai dengan warna biru.)

15
What actions must be completed to ensure the
safety of users or the general public?
(Aksi apa saja yang harus dilakukan guna memastikan
keselamatan pengguna atau publik secara umum?)
Who will ensure that the correct standards are met
or that the correct permits or endorsements have
been obtained?
i.e. engineer, site manager, project coordinator,
local authority etc

(Siapa yang akan memastikan bahwa standar yang benar

terpenuhi atau dukungan dan perizinan yang benar telah
diperoleh? Contohnya, insinyur, insinyur lapangan, koordinator
lapangan, otoritas lokal, dan lain-lain.

Training of local people as operators for
equipment maintenance.
Follow up & monitoring of local community
- The Project Coordinator will train local people
and assess their ability to carry out
maintenance work.
- The project coordinator will assist local
community

3. Please outline the Covid-19 situation at your project location, and if local government policies and
regulations will allow for the activities to progress.
(Mohon uraikan situasi Covid-19 di lokasi proyek Anda, dan jelaskan jika kebijakan dan peraturan pemerintah setempat
akan memungkinkan berjalannya proyek kegiatan tersebut)

The Covid-19 situation at the project site tends to be normal, there are no significant daily and active cases and has
decreased in the last 2 weeks. The local government of Cianjur district has also not implemented activities for the
community.

4. Please describe relevance of the proposed project in light of Covid-19.

(Mohon jelaskan relevansi proyek yang diusulkan dengan konteks Covid-19)

There is no relevance between the project and the context of Covid-19

5. Please explain what precautionary measures you will use to protect against the spread of Covid-19 in
conducting your activities.
(Mohon jelaskan tindakan pencegahan apa yang akan Anda gunakan untuk mencegah penyebaran Covid-19 dalam
menjalankan kegiatan proyek Anda)

The preventive measures that will be taken are to require all personnel involved to use masks and other necessary
protective equipment, provide hand sanitizers, and limit the personnel involved to prevent significant.

6. Please provide the following addional documents,

(Mohon sediakan dokumen tambahan di bawah ini,)

a. comprehensive risk mitigation, including COVID19 risk mitigation

(Dokumen komprehensif mitigasi risiko, termasuk mitigasi risiko Covid-19)
https://drive.google.com/drive/folders/1YrCW3B0v0hStB6oUOW2kqd0LPZgGhaai?usp=sharing
b. comprehensive health and safety plan
(Dokumen komprehensif rencana kesehatan dan keselamatan terkait Covid-19)
https://drive.google.com/drive/folders/1YrCW3B0v0hStB6oUOW2kqd0LPZgGhaai?usp=sharing
c. organization’s central safety and security plan (if any)
(Dokumen utama rencana keselamatan dan keamanan organisasi (jika ada))
https://drive.google.com/drive/folders/1YrCW3B0v0hStB6oUOW2kqd0LPZgGhaai?usp=sharing

CHECKLIST
(Daftar Periksa)

16
Have you:
(Sudahkan anda) :

 Completed all sections of the form?

(Mengisi seluruh formulir aplikasi dengan lengkap)?
 Enclosed quotations/invoices/purchase orders for the materials or equipment you seek?
(Melampirkan dokumen penawaran/faktur jual beli/dokumen permintaan untuk peralatan/
perlengkapan yang Anda perlukan? )
 Attached lists of names of those implementing the project?
(Melampirkan daftar nama-nama yang terlibat dalam implementasi proyek)
 Enclosed all necessary information/documents mentioned above
(references, COVID risk mitigation, health and safety plan)?
Melampirkan seluruh informasi/ dokumen yang diperlukan sebagaimana disebutkan di atas
(pemberi referensi, mitigasi risiko COVID, rencana kesehatan dan keselamatan)?
 Signed below?
(Menandatangani bagian di bawah ini?)

Application submitted by:

(Aplikasi diajukan oleh):

Name: Dr. Mohammad Ihsan A.Md., S.T., M.T., M.Sc

(Nama)
Title : Dean Of Faculty of Engineering and Computer Science
(Jabatan dalam
organisasi)
Signature :
(Tanda tangan)

Date : 20 December 2022

(Tanggal
pengajuan)

17