PEMERINTAH PROVINSI NUSA TENGGARA TIMUR

DINAS KOPERASI, TENAGA KERJA DAN TRANSMIGRASI

bersama
UNIVERSITAS NUSA CENDANA

APPLICATION INFORMATION
A. INSTRUCTIONS FOR THE APPLICANT:
 Answer questions 1 through 8 clearly and completely (in English, typewritten). Do not change the lay out of the
original form.
 You must submit one application only. Submiting more than one application leads to disqualification.
 The first selection will be held in early April 2019. All shortlisted applicants will be advised for interview in mid
April 2019. The final result will be announced in early May 2019.
 Failure to respond to the selection team’s correspondence / e-mail within 48 hours can lead to cancellation of the
scholarship.
 If at any time after the award is offered, it becomes clear that the applicant has made inacurate or incorrect
declarations in the application, the offer will immediately be revoked.
 Please note that in case you are offered an award, a recent health certificate by an authorised physician will be
required. (Expenses are not reimbursable)
 All decisions concerning the application are binding and confidential. Queries, remarks or complaints regarding
selection issues will not be responded.
 Please only upload the scan of original documents
 Application forms and documents will not be returned.

B. ENCLOSURES:
Attach only certified copies of documents. DO NOT attach original documents .
 Official statement from the employer on seal (materai); question 8; stating that the applicant is allowed to
participate in short course and that he/she is guaranteed to return to the same or at least equal position in the
employer’s organisation. This letter must be submitted together with the application form or at the latest
immediately after receiving the provisional the award;
 The applicants should be 18 – 25 years old by the 1st of April 2019.
 The applicants should be NTT KTP/ID holder.
 The applicants should be drug-free (please sign the attached consent form).
 The applicants should have consent form from parents/spouses (form is attached).
 Please provide any English proficiency documents (beneficial but not essential).
 Curriculum vitae, please see format on website.
 Scan of the highest original education documents (Ijazah SMA/ Diploma/Ijazah S1 and Transcript)
 A personal and original letter of recommendation on letterhead referent’s office (Kop surat pemberi referensi);
 Scan of KTP;
 Scan of passport (valid until six months after the end date of the study programme) to be submitted at the time of
application or within one week after receiving the award;
 Scan of birth certificate;
 A recent photograph (3x4; colour)
 All documents should be uploaded in NTT Tourism and Hospitality website: ntttous.undana.ac.id

The closing date is 6 April 2019.

Applications received after 6 April 2019 and incomplete applications will not be processed.
 PEMERINTAH PROVINSI NUSA TENGGARA TIMUR
DINAS KOPERASI, TENAGA KERJA DAN TRANSMIGRASI
bersama
UNIVERSITAS NUSA CENDANA

APPLICATION FORM
SHORT COURSE 2019

Maria Fransiska Bere

Name

Female
Gender

Jl. M. Sabaat, RT/RW 26/09, Liliba, Kupang-NTT

Address

5371045209950003
KTP Number

iskabere@gmail.com
Email Address

-
GPA SMA

-
GPA D3

3.91
GPA S1

082247197790
Mobile Number

437 (English for Academic Purpose)

TOEFL/IELTS
Score*

21th Jan, 2012

Test Date

*if any

2
 PEMERINTAH PROVINSI NUSA TENGGARA TIMUR
DINAS KOPERASI, TENAGA KERJA DAN TRANSMIGRASI
bersama
UNIVERSITAS NUSA CENDANA

APPLICATION FORM
INTERNSHIP PROGRAM 2019
Please note that any false and/or incomplete declaration will lead to the termination of the award.
1. Personal Information
All data exactly as they (will) appear in your passport !

Name Maria Fransiska Bere Male  Female 

th
Place/Date of Birth Place: Kupang Date: 12 Sep, 1995
Marital Status Single  Married  Children 
Email Address 1. iskabere@gmail.com 2.
NIP for Public Sector Applicant

Jl M. Sabaat, RT/RW 026/009, Liliba, Kupang-NTT

Home Address

Telephone / Fax / Mobile Home

** obligatory
Mobile Phone **: 082247197790
National Identity Card (KTP)
Nr. 5371045209950003 Date of issue: 20/1012 Date of expiry: -
details
Parents’ address
(or next of kin)
Jl M. Sabaat, RT/RW 026/009, Liliba, Kupang-NTT
Tlp 085239393027
Telephone / E-mail

2. Education
a. Elementary School (SD)

Type of school Private School

Name of school SDK DONBOSCO 1
City and Province Kupang-NTT
Year of graduation 2007

b. Junior High School (SMP)

Type of school State School

Name of school SMP NEGERI 2
City and Province Kupang-NTT
Year of graduation 2010

3
c. Senior High School (SMA)

Type of school State School

Name of school SMA NEGERI 3
City and Province Kupang-NTT
Year of graduation 2013

d. Undergraduate Education
Please enclose certified copies of relevant diplomas, degrees, certificates and transcripts.

Name, place, country of UNIVERSITAS NUSA CENDANA, Kupang-NTT, Indonesia

institution
Field of study Electrical Engineering
Diploma or degree obtained  S-1 (or equivalent) Year of graduation 2017

3. Foreign Language Ability

Please enclose any English proficiency documents
English:  excellent  good  fair  elementary
Dutch:  excellent  good  fair  elementary  not at all
French:  excellent  good  fair  elementary  not at all
German:  excellent  good  fair  elementary  not at all
Others:  ………...  …………  ………  ………….  ………….

4. Present Employment

Name of Institution / Company / Siloam Hospitals Kupang

Organisation

Siloam Hospitals Kupang is healtcare/medical care provider

Brief description of the
which provides international health services that have many specialists
company and the service it
provides with local patients and tourists

1. Central Government
2. Local Government
3. State University
4. Private University
Type of organization
5. Media
6. Non-Governmental Organization (NGO)
7. Other Educational Institute
8. BUMN
9. Private Company

Telephone: (0380) 8530900

Fax:
Jl. RW Monginsidi, Fatululi, Oebobo
Address
E-mailAddress:
maria.bere@siloamhospitals.com

Website: www.siloamhospitals.com
Employed Since (dd/mm/yy) 9/10/2017 – 16/02/2019

Current position Admin FMS-GA-K3 Employment for 45 hours a week

4

Describe your current duties and
responsibilities
This position held since
(dd/mm/yy)
Make a call and answer, daily maintenance data entry, making monthly, quarterly,
annual reports, correspondence, equipment stock opname, ordering supplies of
office equipment and materials, vendor payment processes for hospital projects,
coordination with security, cleaning service and public relations
9/10/2017 – 19/02/2019

5. Motivation Statement
The statement should be typewritten and composed only by the applicant him/herself. It is not allowed to extend the available
space

No. Criteria Explanation

A. Explain in 50 words which
experiences/considerations have
contributed to your reasons for
applying
to this internship program.
In my work at an international hospital, I often having to replace
other staff who were unable to attend, I had a little difficulty
understanding and explaining in detail the services needed by
patients, especially tourists, therefore with this program I was
expected to do it best so that health services could be good.

B. Explain in 100 words the relevance of
this internship program to your
passions, personal development, and
the organization/sector you work in.
The better I speak in a foreign language, the more confident I am
in working and helping while teaching my coworkers who have
not been able to. We often avoid calls from tourist patients because
fearness or because missunderstanding of what is being said, or we
have to translate the language very slowly so the other important
calls are delayed. This is very influential in the process of work
because 24 hospital hour services are related to patient safety so
that a fast and appropriate response is needed. Besides that at the
hospital there is also no language course for all staff so
communication problems often occured.

C Describe in 100 words how this
internship program will benefit the
promotion and development of
tourism sectors in East Nusa
Tenggara Province in the future.
With this internship program, can solve the problem of limited
NTT youth funds to develop themselves in language skills. More
and more NTT young people are experienced in handling
problems with tourists because they communicate well. The
tourism sector is the main attraction of tourists, but other sectors
also strongly support the convenience of themselves such as
administration, transportation, healthcare, trade and many others.
The more diverse youth from various sectors recruited by this
internship program, the better tourist experiences, and its not only
promotes tourism sector, but also promotes various sector by their
good experiences while living in NTT to the surrounding
environment.

6. Scholarship

Have you ever been awarded a scholarship?  Yes  No

If so, from which organisation? From State organisation thats Bidikmisi Scholarship

5
For what period, for which course/institution
and in which country has it been granted?
For which other scholarship programme(s)
are you also applying at this moment?
7. Miscellaneous
How did you find out about the this Short
Course Programme FOR THE VERY
FIRST TIME?
(please take time to fill in this question, to
enable us to develop the best promotion
strategy)
Where/How did you get the information
about course for which you apply?
8. Applicant’s Declaration
For 4 years lecture, for Indonesia.
Not else.
(TICK ONLY ONE ITEM)
 NTT Province Website
 NTT Presentation (please indicate ...............................)
 Article in print media (please indicate ………………………)
 Advertisement in print media (please indicate ……………..)
 Radio (please indicate…………………………)
 Your Institution
 Regent’s Office in NTT Province
 Friends
 Others (please Indicate …………….....................................…)
(TICK ONLY ONE ITEM)
 NTT Province Website
 Official Website of UNDANA
 Friends
 Your Institution
 NTT Province office in Kupang
 Regent’s Office in NTT Province
 Others (please indicate................................................................)
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I completely understand the conditions under which the award is offered, and if I am awarded an offer
I agree:
1. to comply with all the formal obligations mentioned in the Rules & Regulations.
2. to return to my home country, my home province, East Nusa Tenggara immediately after the program has
ended, regardless of the time remaining on my visa, or at any time immediately;
3. to be available for the entire period of the internship programme and be able to take part in the entire
programme.
4. to give permission to enter my personal data in a database which may be used in East Nusa Tenggara Province
discretion to provide information to other related (non commercial) organisations.
5. to abide by the rules and regulations governing the student visa and stay permit;
6. to submit any progress reports whenever required, about the development of Tourism in East Nusa Tenggara
Province in particular;
7. to act in such manners that will not bring disrepute or cause any formal damages to any parties involved in the
program including the host institution, the image of Indonesian students in Australia, and accept to be called
back to Indonesia, to East Nusa Tenggara Province without any formal appeal in case I breach this promise;
8. to participate in activities organized in relation to the scholarship during the internship program and after I
have returned to East Nusa Tenggara Province, Indonesia;
9. not to engage in employment in Australia other than the allowed maximum of ten hours a week, and to inform
and update committee of any details of such employment if any;
10. to inform committee immediately should I visit East Nusa Tenggara Province, Indonesia for any reason during
the time frame of my internship program and that if I fail to do so my scholarship may be terminated.
11. not to hold another scholarship that would give any overlapping benefits without committee’s written
approval.
Furthermore:
12. I am not aware of any medical condition (disability, illness or pregnancy) which might prevent me from
completing my study programme within the time allowed for the scholarship.
13. I fully understand that if I am awarded a scholarship, it may be subsequently withdrawn if I fail to make
adequate progress, or for other sufficient cause determined by the Government of Australia or the institution at
which I am studying.
14. I commit to inform committee immediately of any circumstances (serious illness, incapacity, pregnancy, arrest,
exclusion, death of relatives, problems at home etc.) that might affect the progress of my study. I realise and
consent that committee may terminate the scholarship and call me back to Indonesia.
15. If reports from the host institutions give reason to doubt a successful continuation of the study, the scholarship
may be terminated with immediate effect.

I certify that all my answers are true, complete and correct.

Date :

Name :

Place :

Signature : materai

THE ORIGINAL APPLICATION FORM AND ITS ANNEXES TOGETHER WITH A COMPLETE
COPY SHOULD BE SENT TO:
DINAS KOPERASI TENAGA KERJA DAN TRANSMIGRASI
JALAN FRANS SEDA NO. 336
KUPANG NTT