Name FacultyAJniversity

Semester/Student ID

GOODWILL LEADERSHIP DEVELOPMENT SCHOLARSIP PROGRAM Application 2012-2013

Please,answerevery questionwith capitalleftersand attachall the information relatedto the questions

1.

PersonalData
Name Date and place of birth Religion Marital status (single/married) PresentaddresVtelephone Home address/telephone
School address/telephone

Email address Emergency contact /address/telephone. Person Type of accommodation (parents/relatives/dorm/ rented room/other - please state)

Hobbies/interests

FamilyInformation
Father
Name: Address: Job: Grosssalary (oleaseattach evidence)
Level of education

Mother

Brothers/sisters How many? What age? Additional comments

Brothers

Sisters

Name

FacultyAJniversity Semester/Student ID

3.

FinancialData

How muchis your annualtuition fee? Please whatyou actuallypaid in 20lt-12 list

How much is your actual monthly expenses? Please specify.

Housing Food Transport Schoolbooks/stationary Other Total

Pleaselist all sourcesof income you received per month from January to November2011,from where and how much?

Parents Other family members Scholarship Job Other Total

How did you cover your schoolfeesand other monthly expenses?

Presentpaid job and position? How many hours do you work every month? How much do you earn every month? How long haveyou had this job?

4.

Scholarship

Have you ever received any scholarshipaward in the past two years? If you have,please
list from where, how much, how long.

5.

AcademicInformation
Elementary school
Comments

FacultyAJniversity Semester/Student ID

Middle Schoot
Comments

High School
Comments

University attending
Faculty

Depalment

Year of entrance

Year of study/semester in August 2012 - January 2013

Year/monthto completestudy Gradepoint Average(GPA or IPK) for past 3 semesters (pleaseattachoffi cial transcripts) Have you receivedany awards from your university lfyes, pleaseexplain. List completedcertified courses, and how long you took eachcourse. (English,computercourse,etc)
List your academic and non academic achievements

FacultyAJniversity
Semester/Student ID

6.

Non.academ experiences ic

4.1 Please your organizational list experiences position/syou haveheld during the past and threeyears.

4.2Pleaselistyourextracurricularandvolunteeractivitiesd@

4.3 Please your paidjob experiences positionsyou haveheld auring the pastthree list and years.

4.4To which activity or interesthaveyou madethe greatest commitmentor contribution? Why? What do you feel you haveaccomplished?

Name

7.

References

Faculty/[/niversity Semester/Student ID

Pleaselist and attach(3) recommendations from the following 3 people.

l. Academic Advisor (PA) Name: Position: Telephone: Email:

2. Head Department ( Ketua Jurusan )

Name: Position: Telephone: Email:

3. Local Authority (Ketua RT or LIIRAII)

Name: Position: Telephone: Email:

Check list of Attachments

References----'1,23 (S.7) & Answers Additional to (S.8) Questions Profile(S.8) E s s a y- 1 , 2 & 3 ( S . 1 0 )

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Student'ssignature: Date: