_________________________________
Field of Training
Program to Extend Scholarships and Training to Achieve Sustainable Impacts Phase II (PRESTASI II) provides
opportunities for Indonesians to earn Masters degrees which focus on areas that are relevant to the achievement
of USAID/Indonesia and Government of Indonesia development goals.
PRESTASI II offers fields of training as follows: Education, Health and Environment. Indicate your preference(s)
by filing in the number 1-3 on the left column. The number should reflect your priority rank of the proposed field of
study. You may choose up to 3 options under the same Field of Training.
Education U.S. University
Information Communications Technology (ICT) in
teaching methodologies as it relates to vocational or
higher education
Curriculum development in vocational and technical
education
Workforce development
Hospital Management
Environmental Health
Nursing and health care
Biostatistics / Epidemiology
Infectious Diseases and Vaccinology
Hospital Management
Health system strengthening: health
financing/economics, health management and
policy, data information management, logistic supply
chain management and health insurance
Nursing Management and Health Care
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
Applicant Name:
_________________________________
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
Applicant Name:
_________________________________
2.
3.
4.
4 copies
(attach to each copy of application form)
5.
4 copies
(attach to each copy of application form)
6.
1 copy
7.
1 copy
8.
3 copies
Supplementary Documents
Please put check mark () if you are attaching the following documents in support of your application
9.
10..
1 copy
1 copy
Important
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
Applicant Name:
_________________________________
To expedite the process, please pay attention to the following instruction below:
Put together all documents and arrange them into 4 separate sets. Each set should contain documents as
described above and every set should be in the same order. Please see below example:
Original Form
(No 1 10)
Copy 1
(No 1 5)
Copy 2
(No 1 5)
Copy 3
(No 1 5)
Please do not bind the documents. Please use paper clips to expedite the dividing process.
Newspaper or magazine
Television
Brochure or flyer
Radio
Advertisement at university
Application Delivery
Application packages should be delivered via post / mail or hand-delivered to IIEF office to the below address:
USAID Scholarship PRESTASI Program
Menara Imperium, 28th Fl. Suite A
Jl. HR Rasuna Said Kav.1, Kuningan, Jakarta 12980
The application packages should arrive at IIEF office at the latest on March 14, 2014, before 4.30 PM. No
documents are allowed to be sent via email or fax. Late or incomplete application will not be considered.
Early application submission is highly recommended.
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
Applicant Name:
1.
_________________________________
PERSONAL INFORMATION
Please give your personal details exactly as it appears on official documents (National ID, Passport, Birth
Certificate, etc.). Each field is mandatory.
First Name
Middle Name
Last Name
KTP Passport
(color or B/W)
4x6
Place of Birth
No:_________________________________
Expiry Date (DD/MM/YY):_______________
Gender
Male
Female
Nationality
Residential Address:
City
Province
Postal Code
Mobile no.
*please write down the code area
2.
Marital Status
Category
Visual impairment
Hearing impairment
Physical impairment
Please specify
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
Applicant Name:
3.
_________________________________
EMERGENCY CONTACT
Details of a person that we can contact in case of emergency. You should provide 2 emergency contacts.
Name
Residential Address:
City
Province
Postal Code
Mobile
Phone
Home Phone
*please write down the code area
Email Address
Relationship to you
Name
Residential Address:
City
Province
Postal Code
Mobile
Phone
Home Phone
*please write down the code area
Email Address
Relationship to you
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
Applicant Name:
4.
Type of test
Date of test taken
(DD/MM/YY)
5.
_________________________________
TOEFL
ITP
TOEFL
IBT
IELTS
Overall score
Test Location
Field of Training
Location of study*
Indonesian University
U.S. University
Briefly describe the reason why you choose the above study. It should not be more than 100 words. Additional paper is not
allowed. This section is mandatory.
Second Priority
Field of Training
Location of study*
Indonesian University
U.S. University
Briefly describe the reason why you choose the above study. It should not be more than 100 words. Additional paper is not
allowed. This section is mandatory.
Third Priority
Field of Training
Location of study*
Indonesian University
U.S. University
Briefly describe the reason why you choose the above study. It should not be more than 100 words. Additional paper is not
allowed. This section is mandatory.
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
Applicant Name:
6.
_________________________________
PROPOSED UNIVERSITY
If you have no particular preferences and would like PRESTASI to identify a suitable institution for you, proceed to
section 7.
First Choice of University
Complete Address:
Name of University
Faculty / Department
Have you requested
admission to the university
Are you receiving or applying
to get funding support
Yes
Yes
No
No
Yes
No
Yes
No
Contact Person
Email
Second Choice of University
Complete Address:
Name of University
Faculty / Department
Have you requested
admission to the university
Are you receiving or applying
to get funding support
Yes
Yes
No
No
Contact Person
7.
EDUCATIONAL BACKGROUND
List of universities and colleges attended. Start with the most recent one. If you are in the process of finishing
your study or attended graduate program but not completed, please indicate in the below table.
a.
Name of
Institution
Degree Obtained
City
Country
Faculty
Major
Start Date
(MM/YY)
End Date
(MM/YY)
GPA
Name of
Institution
Degree Obtained
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
Applicant Name:
City
Country
Faculty
Major
Start Date
(MM/YY)
c.
GPA
Degree Obtained
City
Country
Faculty
Major
End Date
(MM/YY)
GPA
Name of
Institution
Degree Obtained
City
Country
Faculty
Major
Start Date
(MM/YY)
e.
End Date
(MM/YY)
Name of
Institution
Start Date
(MM/YY)
d.
_________________________________
End Date
(MM/YY)
GPA
Name of
Institution
Degree Obtained
City
Country
Faculty
Major
Start Date
(MM/YY)
End Date
(MM/YY)
GPA
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
Applicant Name:
8.
_________________________________
SCHOLARSHIP HISTORY
Please record any scholarship or fellowship that you received in the past, starting from the university level.
Additional paper is allowed if necessary.
Yes No
Have you ever received any scholarship or other funding support from any institution?
*if no, proceed to the next section
Level of
Education
Scholarship title
Start date (DD/MM/YY)
Scholarship
Provider
Contact Person
(Name & Email)
Funding
Full
Partial
Type of scholarship
Degree
Non degree
Level of
Education
Scholarship title
Start date (DD/MM/YY)
Scholarship
Provider
Contact Person
(Name & Email)
Funding
Full
Partial
Type of scholarship
Degree
Non degree
Level of
Education
Scholarship title
Start date (DD/MM/YY)
Scholarship
Provider
Contact Person
(Name & Email)
Funding
Full
Partial
Type of scholarship
Degree
Non degree
Level of
Education
Scholarship title
Start date (DD/MM/YY)
Scholarship
Provider
Contact Person
(Name & Email)
Funding
Full
Partial
Type of scholarship
Degree
Non degree
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
10
Applicant Name:
_________________________________
9.
EMPLOYMENT HISTORY
List your work experiences since university until present. Start with the most current one. Additional paper is
allowed if necessary.
a.
Name of
Institution
Position Title
Full Address :
Phone
Employment
category
Email address
Government Institution
Private Institution
Research Institution
University / School
Media
NGO
Entrepreneur / Freelance
Other, please state:
___________________________
Responsibility:
Level of staffing:
Low rank
Middle rank
Top management
Not applicable
b.
Name of
Institution
Full Address :
Position Title
Start date (MM / YY)
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
11
Applicant Name:
_________________________________
Name of
Institution
Position Title
Full Address :
10.
COMMUNITY SERVICES ACTIVITIES
List professional, societal or other organizations in which you now hold membership or have been active in the
past. You are allowed to use additional paper if necessary.
a.
Name of institution
Start date (MM/YY)
Address:
b.
Name of institution
Start date (MM/YY)
Address:
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
12
Applicant Name:
_________________________________
Name of institution
Start date (MM/YY)
Address:
11.
PUBLICATIONS AND ARTICLES
List of publications and articles relevant to your application. Please attach the copy of your articles or the cover
page of your publications. You can use additional paper if you need more space. If it is not applicable, please
proceed to the next section.
a.
Title
Publication date
Publishers name
Co writer (if
applicable)
b.
Title
Publication date
Publishers name
Co writer (if
applicable)
c.
Title
Publication date
Publishers name
Co writer (if
applicable)
d.
Title
Publication date
Publishers name
Co writer (if
applicable)
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
13
Applicant Name:
_________________________________
12.
AWARDS
List of significant awards and accomplishments relevant to your application, starting from university level.
Please use additional paper, if you need more space. If it is not applicable, please proceed to the next section.
a.
Name of award
Year of award
Scope of award
District level
Regional level
National level
International level
Scope of award
District level
Regional level
National level
International level
Scope of award
District level
Regional level
National level
International level
Scope of award
District level
Regional level
National level
International level
Scope of award
District level
Regional level
National level
International level
Award provider
b.
Name of award
Year of award
Award provider
c.
Name of award
Year of award
Award provider
d.
Name of award
Year of award
Award provider
e.
Name of award
Year of award
Award provider
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
14
Applicant Name:
_________________________________
13.
SHORT ESSAYS
Please note that your answers should not be more than 250 words for each question. Anything over this limit will
not be considered. Attach additional paper if necessary.
PERSONAL INFORMATION
a.
Briefly describe your personal background and daily activities, including interaction with your family members and
community.
b.
Briefly describe significant factors that have influenced your educational and professional development. What challenges
have you overcome in pursuing your professional development? Describe the challenges as well as any insights,
perspectives or skills you gained in overcoming them.
d.
What is the topic that you are interested in for your future research? Please elaborate more on the mentioned topic.
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
15
Applicant Name:
_________________________________
SOCIAL ACTIVITY
e.
Please propose a plan on how will you share your new skills, knowledge and perceptions with your colleagues and
community.
f.
If you are awarded the grant, how will you apply your newly-acquired skills and knowledge to develop your country or
region and to improve your performance in your institution?
Illustrate the chain of command in your current institution, which best describe the line of responsibility between you and
your supervisor(s), colleagues and/or your subordinate.
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
16
Applicant Name:
_________________________________
h.
Please give example(s) on how you demonstrated your leadership skills on your daily activities, whether in your current or
previous employment, or within the community.
i.
If you are awarded the grant, briefly explain your major concern(s) during your future study and your plan to overcome
these concern(s).
j.
Briefly describe your professional goals and how they are related to major problems in your country or region.
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
17
Applicant Name:
_________________________________
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
18
Applicant Name:
_________________________________
14.
REFERENCE SUMMARY
Please provide the data of your referees. The referees should not have family ties with you. This section should
stay attached with the application form.
a.
Institution
Telephone
b.
Position
Professional relationship
to you
Please check only one box
Institution
Telephone
c.
Lecturer or Professor
Employer or Job Supervisor
Research Advisor
Other:______________________
Position
Professional relationship
to you
Please check only one box
Lecturer or Professor
Employer or Job Supervisor
Research Advisor
Other:______________________
Institution
Telephone
Position
Professional relationship
to you
Please check only one box
Lecturer or Professor
Employer or Job Supervisor
Research Advisor
Other:______________________
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
19
Applicant Name:
_________________________________
By my signature below, I certify that, to the best of my knowledge and belief, the information provided in all parts of
my application is accurate and complete. I understand that any false statement or the withholding of any relevant
information may provide grounds for the withdrawal of any offer of appointment or, if an appointment has been
accepted, for its immediate cancellation or termination. If awarded, I agree to comply with any necessary
regulations made by the USAID Scholarship PRESTASI Program.
Note:
If sees fit and with your consent, information contains in this application form might be shared to other
scholarships program under the USAID Indonesia (please check Agree). If you decline (please check
Disagree), your information will not be shared to other scholarship program outside USAID PRESTASI
and this condition will not affect your selection process under USAID PRESTASI.
Agree
Disagree
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
20
Applicant Name:
_________________________________
CONFIDENTIAL
LETTER OF REFERENCE
1.
______________________________________________
2.
Referees Institution
3.
______________________________________________
How long have you known the applicant?
:
4.
______________________________________________
In what capacity have you known the applicant?
Teacher or Professor
Research Advisor
By checking () the columns below, please evaluate the applicant compared to the other students or employees
you have known during your professional career.
Skills
Leadership
Intellectual ability
Knowledge of the field
Work habits
Motivation to pursue graduate study
Initiative
Adaptability
Emotional maturity
Professional integrity
Social commitment
Problem Solving
Excellent
Good
Average
Below
Average
Please circle the number which indicate where the applicant would rank among individuals you have supervised
1
Poor
4
Excellent
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
21
Applicant Name:
_________________________________
Q2. How would you describe the applicants management style? How does she/he motivate people?
Q4. How would you describe the applicants social commitment to his/her community? Please give an example.
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
22
Applicant Name:
_________________________________
Q6. Please give additional facts or comments that may help evaluate the applicant.
You can use either English or Bahasa Indonesia to fill in this reference letter. The letter can be handwritten
2.
or type if possible.
For confidentiality, kindly insert the letter into an envelope, seal and sign it across the border of the tongue,
3.
4.
address:
USAID Scholarship PRESTASI Program
Menara Imperium Lt. 28, Suite A, Jl. HR Rasuna Said Kav.1
Jakarta 12980, Indonesia
The Selection Committee should receive the reference letter no later than March 14, 2014. Late
5.
6.
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
23
Applicant Name:
_________________________________
CONFIDENTIAL
LETTER OF REFERENCE
1.
______________________________________________
2.
Referees Institution
3.
______________________________________________
How long have you known the applicant?
:
4.
______________________________________________
In what capacity have you known the applicant?
Teacher or Professor
Research Advisor
By checking () the columns below, please evaluate the applicant compared to the other students or employees
you have known during your professional career.
Skills
Leadership
Intellectual ability
Knowledge of the field
Work habits
Motivation to pursue graduate study
Initiative
Adaptability
Emotional maturity
Professional integrity
Social commitment
Problem Solving
Excellent
Good
Average
Below
Average
Please circle the number which indicate where the applicant would rank among individuals you have supervised
1
Poor
4
Excellent
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
24
Applicant Name:
_________________________________
Q2. How would you describe the applicants management style? How does she/he motivate people?
Q4. How would you describe the applicants social commitment to his/her community? Please give an example.
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
25
Applicant Name:
_________________________________
Q6. Please give additional facts or comments that may help evaluate the applicant.
You can use either English or Bahasa Indonesia to fill in this reference letter. The letter can be handwritten
2.
or type if possible.
For confidentiality, kindly insert the letter into an envelope, seal and sign it across the border of the tongue,
3.
4.
address:
USAID Scholarship PRESTASI Program
Menara Imperium Lt. 28, Suite A, Jl. HR Rasuna Said Kav.1
Jakarta 12980, Indonesia
The Selection Committee should receive the reference letter no later than March 14, 2014. Late
5.
6.
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
26
Applicant Name:
_________________________________
CONFIDENTIAL
LETTER OF REFERENCE
1.
______________________________________________
2.
Referees Institution
3.
______________________________________________
How long have you known the applicant?
:
4.
______________________________________________
In what capacity have you known the applicant?
Teacher or Professor
Research Advisor
By checking () the columns below, please evaluate the applicant compared to the other students or employees
you have known during your professional career.
Skills
Leadership
Intellectual ability
Knowledge of the field
Work habits
Motivation to pursue graduate study
Initiative
Adaptability
Emotional maturity
Professional integrity
Social commitment
Problem Solving
Excellent
Good
Average
Below
Average
Please circle the number which indicate where the applicant would rank among individuals you have supervised
1
Poor
4
Excellent
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
27
Applicant Name:
_________________________________
Q2. How would you describe the applicants management style? How does she/he motivate people?
Q4. How would you describe the applicants social commitment to his/her community? Please give an example.
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
28
Applicant Name:
_________________________________
Q6. Please give additional facts or comments that may help evaluate the applicant.
You can use either English or Bahasa Indonesia to fill in this reference letter. The letter can be handwritten
2.
or type if possible.
For confidentiality, once the reference letter have been filled in, seal and sign it across the border of the
3.
4.
address:
USAID Scholarship PRESTASI Program
Menara Imperium Lt. 28, Suite A, Jl. HR Rasuna Said Kav.1
Jakarta 12980, Indonesia
The Selection Committee should receive the reference letter no later than March 14, 2014. Late
5.
6.
PRESTASI II Program to Extend Scholarships and Training to Achieve Sustainable Impacts, Phase II
29