UNDERGRADUATE PROGRAM APPLICATION FORM FORMULIR APLIKASI PROGRAM UNDERGRADUATE

PERSONAL DATA DATA PRIBADI Name Nama Home Address Alamat Rumah Postal Address Alamat Surat Menyurat Place & Date of Birth Tempat & Tanggal Lahir Marital Status Status Pernikahan Sex Jenis Kelamin : : : : : : ID No. / KTP No. Tax ID No. / NPWP No. Home Phone / Telp. Rumah Cell Phone / No. HP Email Address Alamat email Nationality & Religion Kebangsaan & Agama Blood Group Golongan Darah Emergency Contact Person & No. Berita Darurat Kepada & No. EDUCATIONAL BACKGROUND ELIGIBILITY KEABSAHAN LATAR BELAKANG PENDIDIKAN The Undergradute Program of Thiess Contractors Indonesia (TCI) is open to all Indonesian students in their minimum Semester 6 of their study who satisfy the following selection criteria and requirements as establish and managed by TCI. Program Undergraduate PT Thiess Contractors Indonesia (TCI) terbuka bagi mahasiswa S1 di Indonesia minimal Semester 6 yang memenuhi kualifikasi dan persyaratan yang ditetapkan oleh manajemen TCI. University of Indonesia Jakarta Bandung Institute of Technology Bandung UPN Veteran Jogjakarta University Universitas Sepuluh November Institute of Technology Surabaya University of Sebelas Maret Solo University of Hasanuddin Makassar Other, please specify name of university and its location: Lainnya, mohon disebutkan nama universitas dan lokasi Mining Engineering Teknik Pertambangan Industrial Engineering Teknik Industri Mechanical Engineering Teknik Mekanik Field of Study Jurusan Electrical Engineering Teknik Elektro Environment Engineering Teknik Lingkungan Chemical Engineering Teknik Kimia Civil Engineering Teknik Sipil Semester Semester Expected Graduation Date Perkiraan Waktu Kelulusan : : Current Accumulative GPA: IPK Kumulatif Terakhir Expected Starting Date: Perkiraan Waktu Dapat Mulai Bekerja : : Geology Engineering Teknik Geologis Accounting Akuntansi Management Manajemen Law Hukum Psychology Psikologi Occupational Health and Safety Kesehatan dan Keselamatan Kerja Other, please specify Lainnya, mohon disebutkan University of Padjajaran Bandung University of Gadjah Mada Jogjakarta University of Airlangga Surabaya University of Diponegoro Semarang University of Brawijaya Malang University of Sriwijaya Palembang : : : : : : : :

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JOB PREFERENCE MINAT KERJA Mine Planning Drilling & Blasting Logistics Maintenance Operation Piping Area of work you are interested Area kerja yang Anda minati Surveying Civil Engineering Community Relations Recruitment Finance & Administration Accounts Payable Mine Operation Procurement Maintenance Planning Data Management Geology Environment Coal Processing Industrial Relations Training & Development Tax Accounting Payroll

SCHOLARSHIPS BEASISWA Have you ever or still obtaining any scholarship from other institution? Apakah Anda pernah atau sedang menerima beasiswa apapun dari institusi lain? Sponsoring institution's name Nama institusi pemberi beasiswa 1 The conditions of scholarship received Kondisi dari beasiswa yang diterima Period Periode Sponsoring institution's name Nama institusi pemberi beasiswa If so, please answer next question Jika iya, mohon menjawab pertanyaan disamping 2 The conditions of scholarship received Kondisi dari beasiswa yang diterima Period Periode Sponsoring institution's name Nama institusi pemberi beasiswa 3 The conditions of scholarship received Kondisi dari beasiswa yang diterima Period Periode Company / Institution's Name Nama Perusahaan / Institusi Date of Application Tanggal Permohonan Company / Institution's Name Nama Perusahaan / Institusi Date of Application Tanggal Permohonan Company / Institution's Name Nama Perusahaan / Institusi Date of Application Tanggal Permohonan Yes : : : : : : : : : : : : : : : No

1 Name of companies or institutions with which you have pending application for scholarships Nama perusahaan atau institusi dimana Anda sedang mengajukan permohonan beasiswa

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GENERAL INFORMATION INFORMASI UMUM Are you in good health? Apakah Anda dalam kondisi yang sehat? If no, why? Jika tidak, kenapa? Please state with dates, any serious illness, allergies, operations, disabilities or accidents, you have had! Mohon sebutkan penyakit serius, operasi/pembedahan, ketidakmampuan atau kecelakaan yang pernah Anda alami beserta waktunya! Have you been refused medical coverage? Pernahkan permohonan asuransi anda ditolak? Do you take alcohol/drugs? Apakah Anda menggunakan obat-obatan/alkohol? If yes, to what extent? Jika iya, sampai sejauh mana? Are you involved in any administrative, civil or criminal case? Apakah Anda pernah tersangkut kasus kriminal, perdata, administratif? Have you ever been convicted in a court of law? Apakah Anda pernah divonis pengadilan? If so, give details! Jika ya, mohon jelaskan! Do you have any other source of income? Apakah Anda memiliki sumber penghasilan lainnya? If so, give details! Jika ya, mohon jelaskan! REFERENCES REFERENSI Name of Referee Nama yang Direferensikan Relationship with Referee Hubungan Dengan Referee Organization and Position Organisasi dan Posisi Phone No and Email Address Nomor Telepon dan Alamat Email Yes No Yes Yes No No Yes Yes No No Yes No

Notification to Candidate Perhatian kepada Pelamar You will not be charged any money or required to perform any service to Thiess or any of its employees in this selection process of TCI Undergraduate Program. Anda tidak dipungut bayaran berupa uang atau diminta untuk memberikan jasa kepada Thiess atau Karyawan dalam proses seleksi Program Undergraduate TCI. If you are requested to pay a fee or perform a service, please report the name of the person, the title of the job you were interviewed for or seeking to be hired for, the date and location where the incident occurred. Jika Anda diminta untuk membayar sejumlah uang atau memberikan jasa, silahkan melaporkan nama orang tersebut, posisi pekerjaan yang Anda diwawancarai atau posisi yang Anda lamar, tanggal dan lokasi dimana hal tersebut terjadi.

I hereby declare that the information provided here in to be true and correct. I have executed this application form for scholarship program and refer you to the person whose names are listed for further information as to my character, ability and verification of matters stated herein. I understand that, if I am accepted in the Undergraduate Program of TCI, my education and experiences will be verified and that any false information on this form is ground for immediate termination of my scholarship. Dengan ini saya menyatakan bahwa keterangan yang saya berikan diatas adalah benar dan jujur. Saya telah melaksanakan apa yang diminta dalam formulir aplikasi untuk program beasiswa ini dan mempersilahkan Anda untuk menghubungi orang yang namanya tercantum disini sebagai referensi keterangan lebih lanjut mengenai watak, kesanggupan saya dan untuk membuktikan apa yang tertera disini. Saya mengerti bahwa, jika saya diterima dalam Program Undergraduate TCI, pendidikan dan pengalaman saya akan diselidiki kebenarannya dan bahwa keterangan palsu dalam formulir ini merupakan alasan kuat untuk menghentikan beasiswa seketika. ________________, ___________________________________________

____________________________ Name & Signature Nama jelas & Tanda Tangan

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