Registration No.

: IPA/2024/00299

APPLICATION FOR MITSUI-BUSSAN SCHOLARSHIP PROGRAM FOR INDONESIA

A. PERSONAL IDENTIFICATION

ID Nasional e-KTP 3404085906060002

Kartu Siswa/No KK 3404085906060002

Name khalila hakimah

( Photo )
Place of Birth Pangkalanbun

Date of Birth 19-06-2006 Age 17

Marital Status Single Gender Female

Nationality Indonesia Religion Moslem

Home Address Kepuh kulon sawo village wirokerten banguntapan bantul yogyakarta

Province Yogyakarta Zip Code 55194

Phone 085878820003 Handphone 085742549364

Email Address dia.milik.yla@gmail.com

Family's Address Desa kepuh kulon sawo wirokerten banguntapan

B. FAMILY MEMBER

Occupation / Living
Name Relation Age Company Name
Position Together?
housewife/busin
suzan aryani mother 40 sausan underwear Yes
ess woman

guntur dwi laksono father 39 worker - Yes

khadijah hashifa sister 15 student - Yes

aisyah sister 13 student - Yes

suhailah sister 10 student - Yes

ziyad al-khair brother 5 student - Yes

C. EDUCATION BACKGROUND

School Name School Address Start (year) Until (year)

SD

MITQ Desa kepuh kulon sawo wirokerten banguntapan 2011 2017

JAMILURRAHMAN

SMP

SWTQ Desa kepuh kulon sawo wirokerten banguntapan 2018 2020

JAMILURRAHMAN

SMA

MADRASAH ALIYAH Desa kepuh kulon sawo wirokerten banguntapan 2021 2024

IPA Score 4th semester IPA Score 5th semester

Math 80 Math 80

English 80 English 80

Chemistry 88 Chemistry 80

Physics 80 Physics 80

Language Certification

TOEFL TOEIC ILTS JLTP

444 - - -

Please give details of any awards or official commendations you have received:

participans world of mental health, mental health promoter voluntary program.

01-02-2024

khalila hakimah