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A P P L I CA T I O N F O R JA PA N E S E G O V E R N M E N T ( M O N B U K A G A K U S H O :

MEXT) SCHOL ARSHIP

Teacher Training Students for 2014


INSTRUCTIONS The application should be t pe!ritten" if possible or neatl hand!ritten in bloc# letters! "#$%&'() * +Nu$bers should be in %rabic figures &%ng#a 'atin( !,-./0,-102&'() * 3 )ear should be !ritten in the %nno *o$ini s ste$ &+asehi( ! 45.%6789(%&'() * : ,roper nouns should be !ritten in full and not be abbre-iated! ;<=>.%67?@A=B(CDEFGCA2'() * H ,ersonal data entered in this application !ill onl be used for scholarship selection purposes" and contact infor$ation such as e$ail addresses !ill onl be used for for$ing acade$ic net!or#s after the student returns ho$e and for sending infor$ation fro$ the .apanese /o-ern$ent0 $IJKLMNOP$Q27.DRSLT$U0%&VW.DX$ e$ail 123456789:;<=>?@AB:C DEFGH6IJKLMNOPEQRSTUV:WXYZ[\]^_`abOcdeEfg:>hijk<lm YSen* Na$e in full in nati-e language DANTONIUS SASMITO ADI WURYAWAN \=]^_** Yoa$il na$e* Yoirst na$e* Y+iddle na$e* In Ro$an capital letters Z+ale [ Zoe$ale ` Y+arital Status* ZSingle ab Z+arriedY gb *

DAGNES NURY FEBRIANI DARMASTUTI cde- Yoa$il na$e* Yoirst na$e* Y+iddle na$e*f &,lease !rite our na$e enactl as it appears in our passport0( hi.jkldmn(oE$%&'( pqr Nationalit pqp .apanese nationalit Z)es" I ha-e p><m ZNo" I donqt ha-e p<<rm

^sf^s1<%&t

3 *ate of birthY 4u vas of %pril 1" 2014 pwrx4 x u r yz r{83 JANUARY 18 )ear 4 +onth u %ge s1 *ate 4|

: ,resent status Yna$e of e$plo er* )our statustoccupationu y} TEACHER

Na$e of the institution !here ou are e$plo edu vw9m S+x ST0 +Ix%y' SUR%x%RT% ~ ,resent t pe of !or# Y*escribe teaching subzects or !or# duties!* yz}.D$Q27'() * MECHANICAL DRAWING AND BASIC ENGINEERING MECHANICS MAKE LESSON PLAN CONDUCT LESSON DO EVALUATION ASIST PRAKTICE SESION ,resent address" telephonetfacsi$ile nu$ber and e$ail address y5Dk5 k ,resent addressY y : PERUM BABUSALAM ASRI 2, BLOK B NO. Telephonet{and,honeY 5 t |}5 : !8 "28#832#$ y$ail address u ant0sas$ito~g$ail0co$ HIf possible" !rite an e$ail address that can be used for periods including the ti$e before ou co$e to .apan" during our sta in .apan" BOTHI NGEMPLAK SUKOHARJO

and the period after ou return ho$e0 AiD &'(

^$LiU2&'(JK& k1%

oield of stud specialied in a uni-ersit or teacher training school in the past Ye as concrete as possible!* -.CL&$'() * TEACHING AND TRAINING EDUCATION DEPARTMENT O% ANGINEERING AND VOCATIONAL EDUCATION MECHANICAL ENGINEERING EDUCATION

,roposed stud progra$ in .apan YIn $ore than ww !ords state the outline of our $azor field of stud and stud progra$ ! This section !ill be used as one of the $ost i$portant references for selection ! )our state$ent $ust be t pe!ritten or !ritten in bloc# letters !f %dditional sheets of paper $a be attached if necessar !* '.DRSAS(A&D1 ww -$%&'(..$& (CDA.1C72) * Those !ho desire $ultiple research topics" $a indicate as $an as t!o research plans0 If ou do so" please indicate the$ clearl b ite$iing such selections0 %lso" selected uni-ersities and fields on the application &%nnen( should be related to this research plan0 &yna$pleu If ou select $athe$atics education research as our first choice and scientific education research as our second" ou $a indicate their respecti-e research plans in this colu$ntspace0 In doing this" be certain to select a uni-ersit t teaching field fro$ the /uideboo#" !hich offers the $athe$atics and science education research training progra$ that ou desire" and indicate it in the %nnen0 AD%&de,&D.+IC72D%27%&'( LD$I%&-.(L(%&'( pRj=6Oj?Rj=6OeE?Z:6Oj=]<lQ6? 2JNeEST6Oj=<EST-Oj?pm:eEQRl If possible !rite in .apanese! _1<%&t.D_$i%&'() *

f ff ffY ff continued f* ff

%cade$ic bac#ground Na$e and %ddress of School =z )ear and +onth of yntrance and Co$pletion 4u yle$entar yducation Y * yle$entar School Na$e Y = * TK KANISIUS DELANGGU 'ocation Secondar yducation 'o!er Secondar School Upper Secondar School 'ocation {igher yducation Undergraduate 'e-el - Y z * To oro$ 1$$$ To
2!!3

*uration of %ttendance 4,

*iplo$a or *egree %!arded" +azor Subzect" #ipped earstle-els

oro$ To oro$ To oro$

f f 4 and f f 4

rs

Y z *

DELANGGU KLATEN

Na$e Y = *

rs

'ocation Y z *

and f f 4 and $ons f f 4 and f f 4 and $ons rs fff and $ons rs rs ffvqr rs ffff

Na$e Y = *

Na$e Y = * SMK ST. MIKAEL SURAKARTA 'ocation Y z *


SURAKARTA

/raduate 'e-el -

Na$e Y = * UNIVERSITAS SEBELAS MARET SURAKARTA 'ocation Y z *


SURAKARTA

oro$ 2!!# To
2!12

Total nu$ber of ears of the afore$entioned schooling 1/CL4,

If the blan# spaces abo-e are insufficient for the infor$ation reuired please attach &a( separate sheets! YY* $KA2$.DA$C7%&'() * Notes ynclude #indergarten education or nurser school education ! Y .KA2) * + Prprtoryfductonfforfuni-ersit ad$ission is included in upper secondar school ! 2&-.$ K&) 3 If the applicant has passed the uni-ersit entrance ualification ena$ination findicate this in the blan# !ith vqr!Y - $C72&$.D1 qr$%&'() *f %n school ears or le-els s#ipped should be indicated in the fourth colu$n &*iplo$a or *egree a!arded" +azor Subzect" S#ipped earstle-els(0 &yna$pleu /raduated high school in 2 ears" etc0( 2&1C72&$.D1 %&!"$%&'(f

#34$1$i%&

rw y$plo $ent record as teachers at ele$entar or secondar educational institutions or teacher training schools egin !ith the $ost recent e$plo $ent! D'(C7}()*}W+I Na$e and location of organiation ,-z
SMK ST. MIKAEL SURAKARTA

,eriod of e$plo $ent ,&. oro$ 200s to NO fro$ to fro$ to )ear pm

,osition /}=
TEACHER

T pe of !or# }
MAKE LESSON PLAN CONDUCT LESSON DO EVALUATION ASIST PRACTICE SESION

,eriod of all e$plo $ent pm

v0foff1prfr pwrx pwrx4 x u r yz

rr State the titles or subzects of boo#s or papers Yincluding graduation thesis authored b applicant* if an () *

!ith the na$e and address of

publisher and the date of publication!Y 2D3314) * K56=D789=D784uD781%&'

rp .apanese language bac#ground if an ! _: ; Na$e of institution :'= %ddress < ,eriod of stud 4. = .apanese language proficienc y-aluate our abilit and fill in !ith an !here appropriate in the blan#s ! $BC1%&'() yncellent D Reading 4 riting Spea#ing % r ooreign language proficienc y-aluate our abilit and fill in !ith an !here appropriate in the blan#s ! G^_1]>?@AD $BC1%&'() yncellent D ynglish H_ orench I_ /er$an J_ /ood E ,oor F
&

fro$

to

:&. )ear 4 +onth u )ear 4 +onth u )ears

_1]>?@AD

/ood E

,oor F

Spanish 8_
KtLr0YfINDONESIANf* M &

rx {a-e ou been a!arded a .apanese /o-ern$ent &+onbu#aga#usho( Scholarship in the past If so" please specif the period" the na$e of the uni-ersit " etc0 NO$^P$Q0JKL'(&W&A+5D&.R-=1'( ; * )es" I ha-e0ffff & fffffffffffffffffffffffff,eriodfffffffffffffffffffffffffffffffffffffffff ff Uni-ersit ffffffffffffffffffffffffffffffffffffffffffffffff ffff<* No" I ha-e not0 pk<m rS! %cco$pan ing *ependents Y,ro-ide the follo!ing infor$ation if ou plan to bring an fa$il $e$bers to .apan !* oTUV%&DoTWUV2&$%&'( %ll enpenses incurred b the presence of dependents $ust be borne b the grantee ! {eXShe is ad-ised to ta#e into consideration the -arious difficulties and great enpense that !ill be in-ol-ed in finding li-ing uarters for the$ ! Therefore those !ho !ant to acco$pan their fa$ilies are !ell ad-ised to co$e alone first and let the$ co$e after suitable acco$$odation has been found !

Y * AoTt$AYP.%67Q0tZ[&DUV0\]1^Q&'(._`iabcde$f$A& +WgThiC7'('LTDQ0t.jklmCDA\]1^QLDUV1nop&'( Na$e q= * Relationship Y r * %ge 4|


2

AGNES NURY %EBRIANI DARMASTUTI

WI%E

rs! ,erson to be notified in applicantts ho$e countr in case of e$ergenc Y uvwx^y- * ; Na$e in full

q= AGNES NURY %EBRIANI DARMASTUTI < %ddress telephonetfacsi$ile nu$ber" and e$ail address *

(5Dk5zd{k1'()

,resent %ddressY y PERUM BABUSALAM ASRI 2 , BLOK. B , NO. 2 , BOTHI , NGEMPLAK , SUKOHARJO Telephonetfacsi$ile nu$berY 5 to% 5 !8 "28#!2!#$ y$ail address u

Occupation

} NURSE | Relationship to applicant

N(} WI%E p I understand and accept all the $atters stated in the %pplication for .apanese /o-ern$ent &+ONUx%/%xUS{Ou +yT( Scholarship for 2014 and hereb appl for this scholarship0 m ~.pwrx4$IJK72&1%67C7C% *ate of application 4u JANUARY 13, 2!1' %pplicantts signature t= %pplicantts na$e

17. Pilihan Tempat Ujian : A. Jakarta B. Medan C. Surabaya


D. Makassar

in Ro$an capital letters m tq=ANTONIUS SASMITO ADI WURYAWAN

E. Denpasar

(Lingkari Salah Satu)

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