MINISTRY OF NATIONAL EDUCATION
THE GOVERNMENT OF THE REPUBLIC OF INDONESIA
Jalan Jenderal Sudirman – Senayan
J A K A R T A 10270
Telp/Fax : 62 – 021 5724707 (direct), 5738181, 5709445 
57111144 Ext. 2610
 
APPLICATION FORM
SCHOLARSHIP FOR MASTER DEGREE PROGRAMS
 
INSTRUCTIONS
 
Please answer each questions clearly and completely.  Type or print in ink. Read carefully and follow all directions. If you more space, attach additional pages of the same size. Submit the completed form, duly signed, in three copies to the Indonesian Embassy/Diplomatic Representative in your country.
 
A. PERSONAL DETAIL
 
  1. a. Family Name :
    b. First Name :
  2. Date of Birth :
  3. Place of Birth :
  4. Male / Female :
  5. Nationality :
  6. Religion :  
  7. E-mail :  
  8. Paspor Number :  
  9. a. Marital status :  
    b. Do you have a husband/wife or any dependants ?  
      (Please give details of name, relationship and date of birth)  
         
   
NO NAME RELATIONSHIP AGE
  10. Permanent address in home country :
   
  11. a. Employment (present)
   
    b. Name and address of organization :  
   
         
B. EDUCATION
         
   
Name and Location of Institution Subject of Study Dates Qualifications Obtained
         
C. LANGUAGE : State profiency Good - Fair - Elementary  
         
   
SKILLS Indonesian English Others
         
D. PROPOSED FIELD OF STUDY  
  (to be answered as detailed as possible)  
         
  1. Subject :  
   
         
  2. Outline your proposed field of study and indicate the practical use to be made of  this study.  
   
         
E. EMPLOYMENT DETAILS  
         
   
Years Descriptions of Occupation Employer
         
F. OTHER  
Experience abroad  
         
   
No Country Purpose Year
         
G. DECLARATION  
         
  If accepted for the scholarship, I agree ;  
    - to  abide by the rules of the university or college  
    - to refrain myself from political activities or any form of employment for profit or gain  
    - to refrain myself from being pregnant and being involved in drug traffichy and abuses  
  I certify that the statement I have made in response to the foregoing questions are true, Completed and correct to the best of my knowledge.
         
         
         
         
 
Date Signature