SCHOLARSHIP APPLICATION FORM

Van Deventer-Maas Stichting

http://extranet.vandeventermaas.org/

This form is used as input for a grant proposal.

All the requested information has to be given.
Be complete to prevent the slow down the proposal process.
Incomplete forms will not be dealt with.

Student Intake
Personal information Periode of 2011/2012

Nirm Your (standardized) identification number

Gender omale ofemale Check the appropriate box

Your name(s). Preferably first name and family (last)

Name
name.
Birth date Your date of birth (dd/mm/yyyy)
Birth place Your place of birth

Region The region from where you originate ("asli")

Street Street and house number where you live

Town Town where you live.

Postal code Postal code of place and street

Phone Telephone number of your house / the closest family

Hp Your hand phone number

Your email address. This is needed for you to log in into

Email
the SAS and for the communication with the PIC.

Your bank name, to which the scholarship is paid. E.g.

Bank name
BNI (and your name printed on Bank Account book)

Bank account Your Account number at that bank

Level of your education. Choose between: S2, S1, D4,

Level
D3, SMK or SMA

Your TOEFL score (max. 1 year for institutional

TOEFL score
TOEFL; 2 years for ETS TOEFL)

Put here a photo of you and give PIC your scanned photo
to be input in VDMS system. Preferred resolution: 72 dpi
Photo and size: not higher than 300 pixels. Programs for
manipulating photos are Photoshop Elements (quite
expensive), IrfanView (free) and GIMP (free).
 Study and Work

Please fill in this space accurately

Date of Final Exam Final examination expected date ( Sidang Skripsi )

General information
Social activities Write down your social and organization activities
(while you are in the with the year of your activities and position in
university/college) organization. For example: Volunteer of
Environment-Go Green Indonesia organization
(2007-present), Committee of Health Teeth
program for SD Cibadak ( 2007), Secretary of
University Choir (2008)
 Grant intake
Grant intake data
Your year of study in the periode of 2011-2012
Current school year:
(2nd,3rd,4th) NOT your semester
Institute: Institute's name
Faculty: Faculty name

Choose: UNIV: Universitas/university (S1, S2, S3),

ACAD: Akademi/ academi (D3/D4), SMA: Sekolah
Institute category:
Menengah Atas, SMK: Sekolah Menengah
Kejuruan

Discipline: Your discipline/major of study.

Your IPK score at the start of the requested period

IPK at the beginning
of 2011-2012 (Latest IPK). Express in two
of the Application
decimals and use a decimal point (#.##)

Your sources of income. Example: Parents 40%

Cofinancers:
School 20% Work 10% Scholarship 30%
 Family and Financial Information
Father's Income /month Rp.
Mother's Income/month Rp.
Annual Income (1 year) of the parents through all sources: Rp.
Your own income (if you are working) Rp.
How do you go to School/University? Public Transportation/ Motorcycle/ Car/ Walk. (Please make a circle on your answer)
With whom do you live? Parents, Uncle/Aunt, Brother/Sister, Alone/Boarding house (Kos-kosan ).(Please make a circle on your
answer)
How much is your monthly pocket money? Rp.
If you live in Boarding house(Kos-kosan ) how much is the cost per month? Rp.

Scholarship/Financial Assistance/Loan etc. received from any source last year

Name of Scholarship / Financial Period for which Amount per

Total Amount Drawn
Assistance / Loan awarded month

FAMILY MEMBERS

Position in Occupation & Name of

Name Single/Married Education Age *
Family the place of Work

Note: if the family member already passed away, write as R.I.P *

FORMAL EDUCATION
Period of Study
School/University Name Major GPA City Source of Income
(Start - End)

Grade in Previous Semesters:

Academic Year IP Semester 1st IP Semester 2nd GPA/IPK
20… - 20…
20… - 20…
20… - 20…
20… - 20…
i.e: 2007-2008 3.52 3.2 3.36

SKILLS
Name of skill(s) Good Fair Less
i.e: Computer Good 
English Fair 

Hereby I certify that the informations above are true.

…………….., …., …., 20…..

*( ) *Full name and signed

 DOCUMENTS TO BE DELIVERED

Please enclose the below mentioned documents along with this application form and give it to the PIC in your School/University.
Give a check mark R on each items in the box to support your application completeness.

1 A reference letter from School/University (Principal/Rector/Dean) stating that you are a member of a
deprived family
o
2 A copy of your ID card (KTM and KTP) o
3 A copy of Family card members/Kartu Keluarga o
4 A copy of Bank Account o
5 The latest KHS in 2010 with the latest GPA(Indeks Prestasi Kumulatif -IPK) o
6
An official income statement of the parents (both government and private) or your income statement if
you are working
o
7 Surat Keterangan Kurang Mampu delivered by Lurah o
8
If there's no official income statement please mention the job and average of the parents' income in Surat
Keterangan Kurang Mampu delivered by Lurah
o
9 Photo o
10 Copies of telephone and electricity for the latest 2 months.
11 A motivation letter in English with short story about yourself, your family, your school/university. Write
about your motivation to apply for a scholarship and about what you expect from it. Signed by you. o

Signature Specimen

Student Signature 1 Student Signature 2

Student Name: Student Name:

University: University:

V.3.VDMS 2010