www.nesoindonesia.or.

id
ots@nesoindonesia.or.id
Jl. H. R . Rasuna Said Kav S-3
Jakarta 12950 – Indonesia
T. (+62) 21 5085 8787

Orange Tulip Scholarship (OTS) Indonesia

Academic year 2022-2023
Application Form
(save with this format: Application Form_targeted university_your name)

1. PERSONAL INFORMATION

Full name ELFRIDA BORNOKTANI GULTOM ☐ Male ☒ Female

Address MARIAH JAMBU DESA POKAN BARU KECAMATAN HUTABAYURAJA

City & postcode TANAH JAWA 21182

E-mail elfridagultom2627@gmail.com

Mobile phone & telephone +60175863261

Birthday (dd/mm/yyyy) 26 – Maret - 2000

Birthplace MARIAH JAMBU

Nationality INDONESIA

2. STUDY PROGRAMME IN THE NETHERLANDS

☐ I am currently applying to one of the eligible programmes
Study programme: -
Institution: -

Current application ☐ I have been accepted by the eligible Dutch institution in one of the eligible study
status programme
Study programme: -
Institution: -
Student ID: -
(See list of eligible programmes and participating institutions at www.nesoindonesia.or.id/ots)
☒ No
☐ Yes (please specify below)

Institution Study programme

- -
Are you also applying to
other institutions under - -
the Orange Tulip
- -
Scholarship?
- -

You can apply to more than one OTS schemes. For each scheme, a separate OTS
application form needs to be submitted.

Orange Tulip Scholarship Indonesia 2022-2023 Application Form

© 29/11/2021
www.nesoindonesia.or.id
ots@nesoindonesia.or.id
Jl. H. R . Rasuna Said Kav S-3
Jakarta 12950 – Indonesia
T. (+62) 21 5085 8787

3. ACADEMIC BACKGROUND
Name of last/current
SMA N 1 PEMATANG SIANTAR
education institution
City & country PEMATANG SIANTAR PEMATANG SIANTAR

Study programme SAINS

Level of degree (to be)
☐ High school ☒ Bachelor ☐ Master ☐ PhD
obtained
(Expected) month &
year of graduation SEPTEMBER 2024
(mm/yyyy)

GPA 2.5 3
out of

English exam score & ☐ IELTS ☐ iBT

☒ I have not taken an exam yet
month + year taken (month+year): - (month+year): -

GRE test result - Month & year taken: -

(if applicable)

GMAT test result - Month & year taken: -

(if applicable)

4. WORKING EXPERIENCE
Current or last working experience (If applicable). Please include your curriculum vitae on a separate file

Company/ organization: KOBE PRECISION TECHNOLOGI

Job position: PRODUCTION TECHNICIAN

Short job description (max. 2 lines): I HAVE WORKED AT THIS COMPANY SINCE 2018 UNTIL NOW. I WORK AS A
PRODUCTION TECHNICIAN

Other working experience(s) (max. 2 lines): -

5. FINANCING YOUR STUDIES

How do you plan to finance your studies at the Dutch higher education institutions (multiple answers possible)?
☐ My own savings ☐ Bank credit/loan
☐ Parents or family ☒ Scholarship(s)
☐ Employer ☐ Other:

Please specify other scholarships that you are applying to:

-

Orange Tulip Scholarship Indonesia 2022-2023 Application Form

© 29/11/2021
www.nesoindonesia.or.id
ots@nesoindonesia.or.id
Jl. H. R . Rasuna Said Kav S-3
Jakarta 12950 – Indonesia
T. (+62) 21 5085 8787

6. CHECK REQUIRED DOCUMENTS

Check the required documents of each scheme at https://bit.ly/indonesiaots

Send the required documents to Nuffic Neso Indonesia (ONLY softcopy to ots@nesoindonesia.or.id) before 1
April 2022 (unless the institution for which you are applying mentions a different deadline on the Orange Tulip
Scholarship website. Incomplete forms and packages will not be taken into account.

Make sure that some universities require applying OTS through its online application system as well. Nuffic Neso
Indonesia don’t take any responsibility if you miss this step.

PLEASE NOTE THAT EACH ORANGE TULIP SCHOLARSHIP SPONSOR MAY REQUIRE ADDITIONAL DOCUMENTATION. PLEASE READ
CAREFULLY THE INFORMATION ON THE NUFFIC NESO INDONESIA – ORANGE TULIP SCHOLARSHIP WEBPAGE

All data will be treated strictly confidential by Nuffic Neso Indonesia and the selected Dutch higher education
institutions, solely for the purpose of the Orange Tulip Scholarship Indonesia programme application.

I certify that the information I have provided in this form is true, complete and correct.

Place : MALAYSIA

Date : 26 DECEMBER 2021

Name : ELFRIDA BORNOKTANI GULTOM

Signature :

Orange Tulip Scholarship Indonesia 2022-2023 Application Form

© 29/11/2021