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BII-MAYBANK SCHOLARSHIP 2013
APPLICATION FORM
UNIVERSITAS YANG DIREKOMENDASIKAN | RECOMMENDED UNIVERSITY
1. Perguruan Tinggi di | Universities in Indonesia  Universitas Indonesia, Jakarta  Institut Pertanian Bogor  Institut Teknologi Bandung  Universitas Padjadjaran, Bandung   Universitas Gadjah Mada, Yogyakarta Institut Sepuluh Nopember, Surabaya

2. Perguruan Tinggi di | Universities in Malaysia and Singapore  Universiti Kebangsaan Malaysia, Kuala Lumpur  Universiti Sains Malaysia, Kuala Lumpur  Universiti Malaya, Kuala Lumpur  Nanyang Technological University, Singapura  National University of Singapore

JURUSAN YANG DIREKOMENDASIKAN | RECOMMENDED FIELD OF STUDIES (MAJOR)
         Ekonomi, Bisnis, Manajemen, Keuangan, Pemasaran, Akunting, Perbankan | Economy,

Business, Management, Finance, Marketing, Accounting, Banking Administrasi | Administration Hukum | Law Komputer dan Teknik Informasi | Computer and Information Technology (IT) Sosial, Politik dan Bahasa | Social, Politic and Language Komunikasi | Communication
Psikologi | Psychology Matematika, Statistik, Aktuaria | Math, Statistic, Actuarial Teknik | Engineering

ALAMAT PENGIRIMAN BERKAS | ADDRESS TO SUBMIT THE APPLICATION FORM
By Post: BII-Maybank Scholarship CSR Unit, Corporate Communication Division PT Bank Internasional Indonesia Tbk (BII), Sentral Senayan III, 25th Floor, Contact and Information Tel : (+21) 2922 8888 Ext : 32503 / 32426 Email : scholarship@bankbii.com Website: www.bii.co.id

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Application Form - 001

com BII-MAYBANK SCHOLARSHIP 2013 APPLICATION FORM Program beasiswa yang dilamar Scholarship Program to apply Beasiswa BII-Maybank Luar Negeri BII-Maybank Scholarship Overseas (TUTUP / CLOSED) Photograph Size 3 x 4 Beasiswa BII-Maybank Dalam Negeri BII-Maybank Scholarship Local (Indonesia) 1. Gelora Bung Karno. DATA PRIBADI PERSONAL DATA* * Semua data harus sesuai dengan nama di KTP/Paspor * All data must be the same with data in Identity Card/KTP/Passport Nama Lengkap Full Name Jenis Kelamin Sex Male (L) Tempat / Place: KTP/Student Card: Passport: Female (P) .. 8. Tempat & Tanggal Lahir Place and Date of Birth Tanda Identitas Pribadi Tanggal / Date : Identity Number Suku Bangsa Ethnic Background Agama Religion Warganegara Citizenship Email Alamat Tetap Halaman/ Page | 2 Application Form . Januari. Asia Afrika No. Jl. Senayan Jakarta Pusat 10270 By Email: scholarship@bankbii.001 .

UNIVERSITAS DAN BIDANG STUDI PILIHAN Universitas – Pilihan 1 UNIVERSITY AND FIELD OF STUDIES TO CHOOSE Jurusan / Major : University – Option 1 Universitas – Pilihan 1 Jurusan / Major : University – Option 2 Target Waktu menyelesaikan studi bulan / months Mulai Bulan / Start from the month of : Sampai bulan / Until the month of : Diterima Tanpa Syarat .. PRESTASI AKADEMIK DI SMA DAN SMP ACADEMIC ACHIEVEMENTS IN HIGH SCHOOL AND JUNIOR HIGH SCHOOL Nama Sekolah Propinsi. Kab/Kota Tahun | Year Halaman/ Page | 3 Application Form . Time target to complete the study Unconditionally Accepted (attached the acceptance letter) Status Penerimaan di Universitas Pilihan Diterima (dengan syarat) Conditionally Accepted (attached the acceptance letter) Masih Proses Acceptance Status in the choice Universities in Process (Submitted the application letter to the university) Belum Melamar Not yet apply KHUSUS PELAMAR PEREMPUAN Apakah Anda juga bersedia untuk dipertimbangkan sebagai pelamar program beasiswa untuk belajar di Asian University for Women in Bangladesh? FEMALE APPLICANTS ONLY Are you willing to be considered as an applicant for the scholarship program to study in the Asian University for Women in Bangladesh? www.org Ya | Yes Tidak | No 3.001 .asian-university. 2013 . Permanent Address Alamat Surat Menyurat Province Province Post Code Post Code Mailing Address Telepon Rumah Home Phone Number Telepon Genggam Mobile Phone Number 2.

Tahun Selesai | Completion Year  Grade UN Nilai | Nilai Rata-Rata | Average Grade per semester  Matematika | Math Ilmu Pengetahuan Alam | Science Bahasa Inggris | English Bahasa | Indonesian 4. School Name SMA | High School : Province. PRESTASI DAN PENGHARGAAN BIDANG AKADEMIK LAINNYA OTHER ACADEMIC ACHIEVEMENT / AWARD Tahun Prestasi / Penghargaan Lembaga Pemberi Year Achievement / Award Institution gave the awards 5.. District/City . AKTIVITAS & PRESTASI BIDANG SOSIAL DAN EKSTRA KURIKULER (SEKOLAH/LUAR SEKOLAH) Halaman/ Page | 4 Application Form .001 . I satu | one II dua | two Tahun Selesai | III tiga | three Grade UN Nilai | Completion Year  Nilai Rata-Rata | Average Grade per semester  Matematika | Math Fisika | Physic Kimia | Chemistry Biologi | Biology Bahasa Inggris | English Bahasa | Indonesian Ekonomi | Economics Akunting | Accounting Sosiologi | Sociology Geografi | Geography Sejarah | History *Kosongkan jika tidak ada/perlu | Leave the sections blank if not applicable SMP | Junior High School : .

province. AKTIVITAS DAN PRESTASI BIDANG KEOLAHRAGAAN DAN KESENIAN ACTIVITIES AND ACHIEVEMENTS IN SPORTS AND ARTS Tingkat diwakili Olahraga / Kesenian Tahun Level represented (school. international) Lembaga Year Sport / Arts Institution 7. Tahun Pelatihan | Trainings Lembaga Halaman/ Page | 5 Application Form .001 .. PELATIHAN YANG PERNAH DIIKUTI TRAINING ATTENDED Bulan. national. district. EXTRA CURRICULAR AND SOCIAL ACTIVITIES & ACHIEVEMENTS (SCHOOL / OUT OF SCHOOL) Tahun Jabatan / Prestasi Aktivitas / Kelompok Lembaga Year Position or Achievement Name of Activity / Group Organisation / Institution Jelaskan tugas dan tanggung jawab | Explain your tasks and responsibilities Jelaskan tugas dan tanggung jawab | Explain your tasks and responsibilities Jelaskan tugas dan tanggung jawab | Explain your tasks and responsibilities Jelaskan tugas dan tanggung jawab | Explain your tasks and responsibilities Jelaskan tugas dan tanggung jawab | Explain your tasks and responsibilities Jelaskan tugas dan tanggung jawab | Explain your tasks and responsibilities 6.

. KEMAMPUAN BAHASA LANGUAGE ABILITY BAHASA INGGRIS | ENGLISH Sangat Bagus Tidak Tahu  Excellent TOEFL Bagus  Good  Average Rata-Rata  Basic Dasar  Unidentified Jenis | Type of TOEFL: Nama | Name of Institution: Nilai | Mark: Sangat Bagus Tidak Tahu  Excellent IELTS International Lokal/ITP: Bagus  Good  Average Rata-Rata  Basic Dasar  Unidentified Jenis | Type of TOEFL: Nama | Name of Institution: Nilai | Mark: BAHASA LAIN | OTHER LANGUAGES International Lokal/ITP: Bahasa | Language Sangat Bagus Tidak Tahu  Excellent  Good  Average  Basic  Unidentified Bagus Rata-Rata Dasar Halaman/ Page | 6 Application Form . . Year Organisation / Institution . . 8. . . .001 . . .. Month. .

Bahasa | Language Sangat Bagus Tidak Tahu  Excellent  Good  Average  Basic  Unidentified Bagus Rata-Rata Dasar 9..001 . INFORMASI MENGENAI ORANGTUA DAN ANGGOTA KELUARGA INFORMATION ON PARENTS AND FAMILY MEMBERS Hubungan Umur Pekerjaan & Nomor Telepon Nama Lengkap Full Name Relations Age Occupation & Phone Number Tel: Tel: Tel: Tel: Tel: Tel: Tel: Tel: Marriage Status Status Pernikahan Pendapatan per bulan Income per month Bapak | Father Ibu | Mother 10. BEASISWA ATAU BANTUAN YANG SEDANG ATAU PERNAH DIDAPATKAN DARI LEMBAGA LAIN SCHOLARSHIP OR FINANCIAL ASSISTANCE CURRENTLY IS RECEIVING OR HAVE PREVIOUSLY RECEIVED Jumlah Jenis Beasiswa | Type of Scholarship Prestasi Akademik/Bantuan/Pinjaman Jangka waktu Lembaga | Institution Amount (Academic Achievement/Bursary/Loan) Duration - Halaman/ Page | 7 Application Form .

will you apply for BII-Maybank Scholarship to studying at 6 (six) recommended Indonesian Universities? Ya|Yes Tidak|No Jelaskan Alasannya | Explain the reason: Jika Anda tidak mendapatkan BII-Maybank Scholarship untuk belajar di dalam negeri. - 11. will you still continue studying in any Indonesian universities (with your own finance)? Halaman/ Page | 8 Application Form . will you still continue studying overseas (with your own finance)? Ya|Yes Tidak|No Jelaskan Alasannya | Explain the reason: Jika Anda tidak mendapatkan BII-Maybank Scholarship untuk luar negeri. APAKAH ANDA JUGA MELAMAR KE LEMBAGA LAIN UNTUK MENDAPATKAN BEASISWA? DID YOU APPLY SIMILAR SCHOLARSHIPS TO OTHER INSTITUTIONS OR PROVIDERS? Ya | Yes Tidak | No Lembaga | Institution: Lembaga | Institution: 12. will you still continue studying in any Indonesian universities (with your own finance)? Ya|Yes Tidak|No Jelaskan Alasannya | Explain the reason: Jika Anda tidak mendapatkan BII-Maybank Scholarship untuk belajar di luar negeri. apakah Anda akan melanjutkan pendidikan di dalam negeri (dengan biaya sendiri)? If you were not accepted to receive the BII-Maybank Scholarship to study overseas in Malaysia and Singapore.. apakah Anda akan melamar BII-Maybank Scholarship untuk belajar di 6 (enam) universitas Indonesia yang direkomendasikan? If you were not accepted to receive the BII-Maybank Scholarship to study overseas in Malaysia and Singapore. apakah Anda akan tetap melanjutkan pendidikan di luar negeri (dengan biaya sendiri)? If you were not accepted to receive the BII-Maybank Scholarship to study overseas in Malaysia and Singapore. MOTIVASI DAN PEMBIAYAAN KULIAH MOTIVATION AND FINANCIAL SITUATION TO STUDY Jika Anda tidak mendapatkan BII-Maybank Scholarship untuk belajar di luar negeri.001 . apakah Anda akan tetap melanjutkan pendidikan di dalam negeri (dengan biaya sendiri)? If you were not accepted to receive the BII-Maybank Scholarship to study in the 6 (six) recommended Indonesian universities.

DAFTAR KELUARGA YANG BEKERJA DI BII ATAU GRUP MAYBANK FAMILY MEMBERS WORKING IN BII OR MAYBANK GROUP Hubungan Nama Lengkap Kantor / Cabang / Departemen Full Name Relations Office / Branch / Department / / / / / / 15.. Ya|Yes Tidak|No Jelaskan Alasannya | Explain the reason: 13. INFORMASI MENGENAI BII-MAYBANK SCHOLARSHIP Halaman/ Page | 9 Application Form . The answer will not affect the application. 14. INFORMASI LAIN DAN KESEHATAN | HEALTH AND OTHER INFORMATION Apakah Anda pernah terlibat tindakan kriminal? Have you ever convicted for any criminal action / behaviour? Jelaskan | Please explain: Ya |Yes Tidak|No Ya |Yes Apakah Anda pernah pergi ke luar negeri? Have you ever been to overseas / foreign countries? Jelaskan | Please explain: Tidak|No Ya |Yes Apakah Anda pernah dirawat di rumah sakit untuk jangka waktu yang lama (lebih dari 7 hari)?* Have you ever been treated in the hospital for a long period (more than 7 days)? Jelaskan | Please explain: Tidak|No Ya |Yes Apakah Anda atau keluarga Anda mengalami kondisi sakit mental atau fisik yang membutuhkan perawatan medis secara teratur atau terus menerus?* Have you or family member ever been treated for a mental illness or physical condition which required medical treatment regularly or continuously? Jelaskan | Please explain: Apakah Anda memiliki cacat fisik tetap akibat bawaan atau kecelakaan?* Have you had any physical disabilities inherited or because of accident? Jelaskan | Please explain: Tidak|No Ya |Yes Tidak|No *these questions do not limit applicant to apply.001 . It is intended to use by the scholarship office to better understand and prepare the applicants if accepted.

Please write your response legibly. Main Office | Kantor Pusat BII. Please explain here the reasons you are applying for BII-Maybank Scholarship and why you are the appropriate person to receive BII-Maybank Scholarship. Branch Office | Kantor Cabang Maybank Group Internet. Halaman/ Page | 10 Application Form .. sebutkan | mention: Ads in Newspaper | iklan di koran sebutkan| mention: Radio University Sekolah | School Pemeran Pendidikan | Education Exhibition Teman | Friends Presentasi | Presentation Iklan BBM | Broadcast BBM Lainnya | Others. INFORMATION ABOUT BII-MAYBANK SCHOLARSHIP Darimana Anda mendapatkan informasi mengenai BII-Maybank Scholarship? (Pilih maksimum 2) BII. Also. You may add additional page if needed. explain what will you do to improve your personal and professional ability during your study under BII-Maybank Scholarship. sebutkan | mention: Where did you get information about BIIMaybank Scholarship? (Choose maximum two ) 16. Jelaskan pula apa yang akan Anda lakukan untuk meningkatkan kemampuan personal maupun profesional selama menempuh pendidikan dengan BIIMaybank Scholarship. Pernyataan harus ditulis dengan jelas. PERNYATAAN MOTIVASI | MOTIVATION STATEMENT Jelaskan di halaman ini mengapa Anda layak untuk mendapatkan BII-Maybank Scholarship. Gunakan lembar tambahan jika dibutuhkan.001 .

001 . jika diperlukan. Saya memahami sepenuhnya apabila ada pernyataan dan informasi yang dengan sengaja salah diberikan atau ada informasi yang dipalsukan.. dari sekolah atau lembaga pendidikan lainnya yang sedang dan telah saya ikuti. STATEMENT OF APPLICANT | PERNYATAAN PELAMAR Saya dengan ini menyatakan bahwa informasi yang saya berikan adalah benar dan saya memberikan kewenangan sepenuhnya kepada Penyelenggara BII-Maybank Scholarship untuk mendapatkan bukti resmi. maka lamaran beasiswa ini akan didiskualifikasi dan jika Halaman/ Page | 11 Application Form .

I hereby declare that the information I am providing is correct to the best of my knowledge. Halaman/ Page | 12 Application Form . I have ticked the left box to confirm that I have read and agreed with above statement. from the schools or other educational institution which I currently attending or have attended. if needed. saya telah membaca dan setuju dengan pernyataan di atas.001 . terbukti benar. I give a full authority to BII-Maybank Scholarship Office to obtain official proof/evidence.. I completely understand that if there are any false statements or information were deliberately given or falsified. maka saya sebagai pelamar atau calon penerima atau jika nantinya diterima dapat diminta dan bersedia untuk mengundurkan diri dari program BII-Maybank Scholarship. TANDATANGAN | SIGNATURE : _______________________________________ NAMA | NAME TANGGAL | DATE : : . Dengan mencontreng kotak ini. my application will be disqualified and if it is proven. then I as a prospective applicant or recipient (if I were accepted) is willing to withdraw from receiving the Scholarship.

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