FORMULIR PENDAFTARAN

PROGRAM BEASISWA UNGGULAN

(KREATIVITAS PARA JUARA)
BIRO PKLN, SETJEN, KEMDIKNAS
Jl. Jenderal Sudirman, Senayan Jakarta 10270
A. KETERANGAN PRIBADI
Nama Lengkap

: ............................................................................

Tempat dan tanggal lahir

: ...........................................................................

Alamat

: ...........................................................................

Foto

: ...........................................................................
Telepon

( rumah )

: ...........................................................................

( hand phone )

: .............................................................................................

( fax)

: .............................................................................................

E-mail

: .............................................................................................

Sekolah

: .............................................................................................

Alamat Sekolah

: .............................................................................................
: .............................................................................................

B. PRESTASI
1. Internasional
a). ........................................................................................................................................*
b). ........................................................................................................................................*
2. Nasional
a). ........................................................................................................................................*
b). ........................................................................................................................................*
3. Provinsi
a). ........................................................................................................................................*
b). ........................................................................................................................................*
4. Daerah/Lokal
a). ........................................................................................................................................*
b). ........................................................................................................................................*
* Setiap Prestasi dimohon melampirkan:
1. Foto kopi Sertifikat/Piagam/Foto Medali
2. Foto dengan pose membawa Sertifikat/Piagam/Medali

C. PESAN/SARAN
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D. TESTIMONY
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Saya yang bertanda tangan di bawah ini, menyatakan bahwa data yang saya isikan diatas adalah
benar.
......................, ................................................20....

( .............................................. )

NB :
Pada saat mengirimkan berkas, selain mengirimkan Formulir ini mohon dilengkapi dengan :
1. Surat Permohonan Beasiswa
2. Daftar Riwayat Hidup/Curriculum Vitae (CV)
3. Publikasi jika ada
Sekretariat Beasiswa Unggulan
Biro Perencanaan dan Kerjasama Luar Negeri
Jl. Jenderal Sudirman Kemendiknas Ged.C Lt.6
Jakarta - 10270
Telp/Fax: (021) 573 111 44 ext 2616, 573 9290
www.beasiswaunggulan.kemdiknas.go.id