IDB-LOAN PROJECT UNIVERSITAS MULAWARMAN

PROJECT IMPLEMENTATION UNIT (PIU)

Formulir Pendaftaran Beasiswa S3 Luar Negeri dan Bridging Program 2015
1. Nama :.........................................................................

2. NIP :....................................................................

3. Tempat/Tgl. Lahir :.............................................................................................

5. Fakultas :.....................................................................

4. Jenis Kelamin: L / P*

6. Program Studi :...................................................

7. Pendidikan :
a. S1
Universitas
Program Studi
b. S2
Universitas
Program Studi

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

Fakultas :...............................................................
IPK
:...............................................................

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

Fakultas :...............................................................
IPK
:...............................................................

8. Rencana Tema Penelitian Disertasi :

............................................................................................................................................................................
............................................................................................................................................................................
............................................................................................................................................................................
9. Rencana PT Tujuan
Jika Ada,

: Ada/Tidak Ada*

Nama PT

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

Nama Kontak/Prof.

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

Negara

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

10. Skor TOEFL/IELTS terakhir

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

Samarinda, Desember 2016

Tandatangan,
()

Prasyarat Dokumen bagi peserta baru

1. Fotocopy NIP
2. Fotocopy Kartu Pegawai
3. Fotocopy Ijazah
4. Fotocopy Transkip S1
5. Fotocopy Ijazah
6. Fotocopy Transkip S2
7. Fotocopy SK Pengangkatan CPNS/PNS/Tenaga Dosen Kontrak ber-NIDK
8. Fotocopy Research Proposal (5 halaman, uk. kertas A4, spasi 1, uk. font 12)
9. Fotocopy Izin Atasan (Dekan/UP Dekan)
10. Fotocopy Bukti Skor TOEFL/IELTS terakhir yang masih berlaku (maks. 2 tahun)
11. Curriculum Vitae : Pendidikan, Pengalaman Publikasi, Seminar, Pengabdian Masyarakat dan Mata Kuliah yang diajar (maks. 3 tahun terakhir)
*Coret yang tidak perlu