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DIREKTORAT JENDERAL MULTILATERAL

KEMENTERIAN LUAR NEGERI
REPUBLIK INDOI{ESIA
JL. TAMAN PEJAMBON NO. 6 JAKARTA PUSAT 10110 TEL. (021) 381 4450 FAKS. (021)384 5774

Jakafta,4 Mei 2011

Nomor i 00704/Tr/05/2011/5r
Lampiran : 1 (satu) berkas
Perihal : Tawaran program bea siswa dari Sultan Sharif
Ali Islamic University of Brunei Darussalam
(UNISSA) tahun ajaran 20IU2012

Kepada Yang terhormat

1. Karo Perencanaan dan Kerja Sama Luar Negeri,
Setjen Kemdiknas
2. Direktur Kelembagaan dan Kerja Sama,
Ditjen Dikti, Kemdiknas
@ Karo hukum dan Kerja Sama Luar Negeri,
Setjen Kemenag
4. Direktur Pendidikan Tinggi Islam,
Di$en Pendidikan Islam Kemenag
Di
Jakafta

Merujuk perihal pokok surat di atas, bersama ini dengan hormat kami sampaikan
hal-hal sebagai berikut:
1. Sekretariat Jenderal Organisasi Konferensi Islam (OKI) melalui nota no. OICIST-
16(16)/20111002L44 tanggal 23 April 2011 menyampaikan bahwa Sultan Sharif Ali
Islamic University of Brunei Darussalam (UNiSSA) menawarkan program bea siswa
bidang studi Al-quran dan Al-qiraat pada tingkat Sarjana, Magister dan Doktor
untuk tahun akedemik 20II120L2. Program bea siswa ini ditawarkan kepadg para
siswa/pegawai yang berasal dari negara-negara anggota Organisasi Konf\si
Islam (OKI), termasuk Indonesia. \
2. Sehubungan dengan hal tersebut di atas, mohon Saudara dapat menyebarluaskan
tawaran bea siswa dimaksud kepada para pemangku kepentingan, Bagi para
peserta yang berminat, aplikasi pendaftaran dapat langsung dikirimkan ke Sultan
Sharif Ali Islamic university atau dikirmkan melalui Konsulat Jenderal Brunei
Darussalam diJeddah.
3. Terlampir kami sampaikan salinan Nota Sekjen OKi terkait tawaran bea siswa
tersebut di atas, beserta salinan formulir aplikasi bagi peserta yang berminat.

Demikian disampaikan, atas perhatian dan kerjasamanya, kami mengucapkan

terima kasih'
,.-; i : ;.

Direkt OI Negara Berkembang

Ternbusn :

Yth. -lt nirjen }tul-tilateral

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Orgunisqti(,rt r:f the Islamic Conferente
Getwrcl Secretariat

Orgunisatic'n d.e Ia Confdrence Islanique

5ecrdt ttr iat G {tt if r al
Ll*I iihtl

olc/$r-16(16Y2011/
0021 4 fh Jedd*h, 2 3 ArR t0l1

The General Secretariat of the Organization of the Islaruic Conference presents its
cornpliments to the Fennanerrt Missions, Embassies and Consulatee General of all
Nlenrber States aril has the honour to infornr that the Sultan Sharif AU Islamic University
of Brrurei Ilarusralam ILINISSA) is offering scholarships for the studies of al-Quran and
al-Qiraat at the Bnclrelor, Masters aud PhD ieveln tvhich will commence in the Academic
Year 201Li}CIl? (i August 2011).

Brochures and apptcation forms for tlte scholarships, reoeived from the Consulate
Gcneral of Brunei Darussalarn in Jeddab are attached.

Mernber States may circulatc ths enclosed inforrnation for the benefit of
interested studerits who can apply directly to the Sultan Sharif Ati Islamic University or
ror.rte their applications ttuough the Consulate C:eueral of Bnmei Darussalam in Jecldah.

The {ieneral $ecretariat avails itsclf of tbr6 opportunity to tenew to the esteemed
Permanent Missions, Embassies and Conzulates General the assurance of its highest
crr:nsicieraticrn.;/
/fe

'I'o: fennsnent Missions, Ernbassies, and Cousuhtes Generel of

the Memtrer States of the Organizntion of the Islsmic Conference (

\o \ Y Y AA : ,*f,r0* lF \ CIt Y Y : Ojdi- I 1 t \ 1 IJ{ - I vA.;,,y

tr.g.Rox 178 - Jedtlah 2141t " Tei.: 6515?12- tr'rx; d5ll?E$ - Ttlebslte: wrw.oic-*ci.crg
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FANDUA}'T MEflCISI DAN M-I,NGHAJ{TAN BOFANG }ER,MOUONAN./

d UIfrELTNEE FON FNUNG W AND SaEHTsSToN oF APTHOANT'IdIN FhE:IT

l) Pcrrohonrnr*tlldrmengiriBor+ngPermohonarrAsoldalr,qdul[2]*tinandu*nr[l]nlhmBorangTnmba]ran,
I topies of thls appllmilonlorn thould bt subniuad

2l Sctiap bcrang hcnilaklah dtlenglcapi dangm salinxr.ratinon dokrrncn ;lplrii bcrikut /Each spFttcd(ionf*n $ould be
sv bmirrcd logclhet wl th the fa ilsvl nE daruwnt t :

[a] Salinur Sijil Rnnruk /a c opy of birth cenlfictu.

[b] Sail**n liad f ?rgwt lw /d tW of I tu u iftatian Card
[d] Ssiiilan Sijil Kar]yann I jika oda / jikr bcrkcmn / a rcpy a{clthewhtq rcnltlcde (tf Wltcdbla,).

ldJ Sqnur Sslinur $iill / Detumm alartcmit yrng bckrlitan/ All rclwut oortifict*s /Acrdarnic C*tifipates

3l Seliap bqrrng hcndnkl*r dilckqrk8n dengan grmbu blbm bcrutulr! pt9lort / Eoth awlicaion forn il|rlald ba
anached$ith a tsce\t paitpd|.t rhe phao $ille oppllcone
r,lJ Pcgarrai / lkkilangrq Ktwcntctian Pcilititilffi! rhn Ifurselrriau lfil
bl$ril Ugsrna hnrrhklah mmde,utu
trarrng po-mohousn kc fftlrrclltcrten bc*rnarnmclrlaui Ksnrrl|}atarlUnit/E&girnmising.madng;

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Fcgeuai Ihktungtrr Kcrqienrr dor Kimertcriflr hin dm $nribrt S*q$! hadaklth nngluotrr b+rng
rnclaluj lirara Jrbatal c Pcgqw&i Kenpntcrin / Pgrgurus Sytd]tt Dsing-ruasing Borrng pcmohonal htnd&lrtr
d isauk* dcngan srrrd'nkongrfl lrbst{d / tfumfftt{itn / Sytrikrt

6J Pemnhon.pcrnohonboli{rlehmr|rghf,ntsr horurg ptnrFhmm tcnrs kc damtbtikut/,{ppliouaformtiloaldbesant

rs llts lsllov;ag qfl{rgts:

Bhhaginn Kcrnrsulsr, B$$nur Pcntadhiru,

Univmsiti Islsrfl $ultm ShrrtfAil,
lalan FmrBlthffr, cndongBEl!|0, .

&runei Daru,:sala,m.

NO_I4_j

I lllo. 4 dm 5 adf,lsh rmluk p?flrohon tanpilin yurg ndrh bcrkc{a sr}rqi* I ito, 4 dan 5 *c app[icoble to in-semlce local
ooplicanft opptlcants only

,l UNISSA b,qrha.k mcnotak bcrwrg pennohonu y*u6 rldak lengklp. meogstdun6i nrklurnnt lnlsu ttau yang dilrirrr.
sctegnstrriklr ruFF pqDglmtffrfl bored& t UNI#A hat the right ro Naat r',tco+4pldtd qpllcantton fprw, lwgcd
dot:uonng ot appltsan&fihlch are wbmilaad aJlet tlu deadline'

ll Pemohoo-pcmohanl"6gbcd{y6.sfllpjs}rn3akandihubungJ/Otrlytvcctstfulapplicanlswlllfuconraclcd,

Jl Pcrnohor.pemohon bolch menghubungi &e Bdragiin Kmusulpn unruk ntmbus pttrtunynsr sdrnJuttp dcngm bilrnf,ar
Telylon tio.: +6?3?162000 atau mehlul email I tpflicar4 may conla.t the Adakilans Seaiartfor
ftrher cldrifrcaticr$ Tsl : +d7J246)000 or endil

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P wty edue b Difbwa / Poslgntvatt Cwtifiutc / fuIes tail Ph D Fmganr*s)
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l, Npnu Penuh I Fall Nane :

Oslgran I fitlc :
(Awg I ti1g,I Mr} lddm / htrr / Ma)

2. Sil. Krd Pargcoulur /

Jdenriry Card No. :
Wma/Cdor,r rI Y-Krming/yethw
R- Ungu / Furptc
G-Hijau/Orea
O-trin"Lrin/CIben

4. U;t$ta/rteirfion 6. Trraf,Kolnrnin I (tlorltalStarus

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Isdkh Dikclusrflnl Darc o{ksar;

Ta'ikh Mnnsuh / Dare of Erpl4r ;

Terupat Dlkrluu|*n J f lace af Issut:

ffiffiffi No. Sljll f,srrlqrrdss (Iilrr borlffist)
Cirizewh{p Cenfcqte No. (if aFpliiabla)

10. Tfirlkh L$rir I Dau of Btrth:

l'crnpnt dan Nugcri dilnhitl$n

Placc ond Count/y of Euth :
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I I l. Ala$lr Pcrturil8n / Cdrnryputdence liddm$i l?, Alrfi* T€trp Paailnn I lpplicutt's parmatgnt Addrt"u:
l

Kod Pos I Post -Cxle : Ko'd Pos /.Parr .Codr :

Tete{on / Tetcphota,
[I - f el:tl)tt l Tblcphone !
m"rrm]rn
Faksi Far, lTr. Tcrcbn Bimbir i.i/orrre rcrerlone:
fil ff,|-JT-il-fn
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Ale$6, t-l'tllll E-Mcltddrws :

13. Orrng iludrb DlhubungV8rudm fordllat (ltrmr & Ahfirt) liubu4ll / rt*lattoarfi p
cartdat P€fi*n/ Nd elnn (Nalllr &nddffir)
Nsru ' Ivd,?rc.' FA=Bnpa/Forfter HU - $usmjl,ftilrbar*f
M0-Ibu//dotfisr vlF=l*siltvtfe
GU - Forrfu,ga I Awrdtan fff = Lain-hin i &Jrers
R'.rnrah,/ffonrz

Pcjabati A/fict:

TeldrnRrnudr
Hws
m
frl
Tcl, Nc,

Tclafor Pej*rt
KoC Pr:s i fart-Cade :
A0ieeTel, tta,

Fc.tteiaan / Odduparinn :
Fdls/Fs
fn
t4.$uuhtr Bhyun /,golrce rf tll
^nO^,
BC - Elnsisnq Kirsjrffi Brunci rntuk warEracgm Bnme- / Rruet Gowrtrnet a S{.holanhtp fw Brunct Cittzen
BS - Biasisws BSP unluk warganogan Brtctri / Brrnsi $hall PcEtbM Sdn Bhd. ^lcloJanhtPf,ff Enttii AilFcn
tp:Curi BrlqierDalaruNcgni untutwsJgucgtrtrBrunai/Ia..ssl"icnfiudtl*weforBrwrf,lCitban
tW = Cull Tfdqk Fcryqii Dslarn Nctffl rxr$k$irgrncgsaErunci/Ift.,Stvidd.Swfu leew llithoat Pry/or BrunelCltisen
lC S'nrlkat Swasra / Private CornpanT-
'
Ps = Sckolalr Swssts / Prrcau School
PO = Ffftubuirin Sw,astn Yrng tiln I Olh$ f rlvate Organisation
PS = Blal.aan PcrsEndiriU / fr[vVte Sndent (SeS$pontoredl
Ol=lain-LoinlOthtru

Adnkahp*nbiayan I k jnarce prwisiond nr canfttmed?

Narng dm alaro.at orang pcnEsdlrion atau organisest yang monbiuyri peogilirn?

,\'omt and eontatt ad*e ss of prson nr otranaotio4 rstPl'rulbllfa. psyfttgyolar felr?
Flama ,' I ame '

Almrt /,1rfdrer;;

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l5a- Na*akan sma rda prnrh r*mctimg bl$i$r{& ktftJrrn N€ln Enroei l}rnrrsrlr uuluk borhrnus di y o ys! yes n
N ='ridak / ilo I
#;il XJ lll),|'ru^
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G wnr ro tato
iocally or overseot

Jike orfa, sila nyrnlln I lfps. ph$e ilnte

Krp{tu3an
lcnpohfut* /Durr,tion
NrmtPtogrut NrmE Inflihjsi d81 Hcf,Gri frewlt

Namt of Programmc Na n e oJ I ns tt tu$u and C ounrry Dari Hlntgn I-.utus i Crgrl

I*ontr to Pow/ Fail

[Sil* sc*akm sulinnn surat dui tfunnotrriel / Isbdm / ASE$i bct*ffsm jib eudrpem* ditsrudtan PtngEnu$rthon
!i1r5i5ws. tcrajuon Nsgara EruFti dnrussalern / Agcnsi bc*iltnm I

I ib. Adolsh awila jugn rocrnOhon Eiasiswa Hrqjaen Enraci Dsrusiillfrn Unurl rmlrrdrrdol polajuun ke luar OegHt $8dL lahun ini?
H m'a yo a a is a opp Ii e d for gmwr nTns n1 sr;ho lars htp for wenew wly thlt yar?

tjkr 6de, wotrj(,Jtn. / tJWs, pleare slat€

{'i) TnrikhXermnhoncn: (il) HamaFrognm:

Dcrc ofappllca$on: Nar,e afFwgronna:

(iii) Nemr lnstttusi (iv) Ncgal:

Nane of hlstiltltaon :
Cour,try:

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I(.E't ULr,"SAI{-KELULUflAN
ACADEI{IC 6aALIFI{]ITION,I (I';lxhf' N&onal tatlf,aas / Dldwa/ F'lf',t Dtr/re / Nan+n bqwe)

Tr,rngchliwur
lirlul"tru Nrmr hrrihxi, rrcgtn frtnadnn Kdrr/6trd/l-rtlu$lOUd Alk.n PinfiEtir

Qualiic;ric'nt hr6 tihitim NtilrE, Cqurlr! Clqu/(na&/ Fwt/ Fail h{edlyn oILi}tgr,agl
Dad mng{
From t'o

I. Drd you rlritc e thcsl$? Iiys, plc$c pmridc thc titlc

2. Did ycu wrire s sch6lnly rfport c.& uticldr, 66ograph? If ya. plcr* proviilr trt ttlt rnd dtmh copirl of tlose articldst
!non08l$plVt.

Tf 1'rur highr,sr cbftryr wa; a Each*lon degrcD, did

you write nry sfsd.dtriq; e:Ktrcirr il univ.triry lwol? Ifyee plr-n* providc titlc and
grrdc ob$.in*d-

EAIIAGI N/dFcTfO/VC
urrtrl diisi otrh p0fiohoD l[!trrprtFn prrptrfthiilnthn rrt{ir /ir fr D€ fi\kd in fu'localpre-wrviw ryFilcdttt oilvl

llkn btnr ms,namdk*r pcngnjiur sih n1-atal{nrr I

[yn lvvrJusl aonyletedywr sltrdy pl€ate il6n :

Namr tclol&hakrah / Institu$i :

h'anur ef School / Collega / Iwltlulion;
Tahur men*na&nq p*ngqiian :
l'earoffionpbtlngyaurtludl: *- --- t €
I Sil, ,sj,taka" r"ltrn cijit prringkst biasa dnrr la{utar I Pleatt a$neh crylet al'O' f41d 74' hvel ctrlllfuara l

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KT,M.IIIIRAN BAI{A8A / LT'VCAIGE EOFICIWCY

Bahasa Menulis Mer*rca Pcrcilspa

Lonp,pgt Wittea RrddL'tg .$pobtt

Boha:a Melalr / i,/a/ay I = staSatBrik/ fuccllznt

2 . Brik/ Good
hgctis / Englirl I ESodfihlfld/Fdlr
Bshnso Atsb /,{rubic

Jika lain, Ny,atakan

llotherc , Fleasr Sla,lt

r ASAGIAN l.}d4"rloJv f'

PEI{GALAM.IJI I(E&IA YA}M LAW I P'/ST WOEE. 4TFEX,d,NEE

NalnaPcrg*t{s lBadsu Jawnn dipagang

Nawe afAux.latlon/Eofi Pasitionhsld

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SaH 6tAt{',SECnON F
f EKEruAAIT SEKARIJ{G I.PTE,Yf,JVf OffUHfIAN

I Jsliaatsn Sekaralg / Pralor ' ,Po^rr

2.. Tcmpnt EerUg*s / Plme of lVork

3. Narnc dm Ahnat Mrjikrur I Earplqet's Ndrle dnd iddlr,rs

4 TffEglran lrubungkrit Frosr$n yf,n$ ditr)honkrn dargm hgrs a*dn.

Indisale lha rslryancc ,?f the proFrw^e(r) @hdlr to lottl ctlrtdnt dellr.r.

||AHAGI^N tEEFIIp.NG
TENgAL^FITT{ KERJA YAI!'C I,ALIJ I FAET VI'Rfr EXPEHEHCE

Nana dan alnmc mqiilun I

Enrpfoyer't Namc and Addntt

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BA$ACIANl/dffflOrYI
PEI{VELDIKAN DITI PEIWNSMAN
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l. Sila srnamik:rn plnyclidiltran yrng rhh rclcsai dnn pcnubihajlla rda

P|ewe llsr completed/escarclv at dpubltcatiow, {ary

2, Silnnycnkonbidangpcng4iisnvsagdicudqngkan lPlearckdloaaptvpadfuHofstvdy:

] Tirjuk Pc11vclidlkan I Rtstmxh Topie ,

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L Sih bcrikan dua nlrm don illsmal orffig yene bokh din$ttk tnr* mudryd* tryrm .tademik
6ivr thp namet ond addnss o{tva ref,ertet towhwreferl,nu nry bz nw& uyow uadanlc record

(i) biarna/ffaru :

Jawallr/ Past.'

Alrmirt / lddr:rs :

Jrlcfon/IgJ:- FE(;- FlYliil:

\

(ii) I'lamr/ffane;

lq\yaFd/ Parl.'

AJruntrt / lddrert r

Telefon / l"e/ I Faxr E-Mell;

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il$r,GIAN/SCCffOirr"ff
P}J{CAKUAN I'}ETIJ$,4T ION

l. Fsinws dcng*n rcsu.rggufiryn sa)s rmng*a Eskiulqft ymg difiyatrie ldslrhb#d drr, btur. $ayrbancn$uahan
,rlorl6lalurirknn kcprda pihrrk Univcr,sitl lsluuSulEn$harifali r*lrnpdtp?tsllhmsdralapcng4iim ssytdillnive$id
lslum Su tian Shrrlf Alt. Sryu jugl tnmgakru b*hr*'E lj:rhr*d Istm ${lhfi $FifAti bfitral untu}. mguboh rtrrr naterilk
b,slilt .rrbunng keputrnur nrcnguroi kctttrgrknn r$a kp Ltqlwr$id Islan suJtrs ghffif Ali jile mrhluox yeg dibcriht
sdrlah lidlk bcrul atru ddak,
I hct'eby certily ailthe)afonrtattonprnvtdedby,neheka*ttandtn* I ilgre lo h{xrra Urdvcrstttlrldtttshsrt/Alit[
iliert k aw clwnge whlle I an srig/)thry at Un},,trTlil Islan SJwf tli , I aha aenfi tlwt UnltYrriti lrlan ffiellAft ris.rlf,s lAe
tight lo vary or reversc 1rry dtctston pefialntng lo W almlsslon ao lJnlnrslti Elan fuffnli {|fu lnfarnaltoa
g!1,sn is ir'coffecl and uiltruc^

Twiklr / Osto fandahngan Pmuhon / Appliofilt's,Sigttdturd

1. Fmgcuhan oluh Prngcfirr/ Guru Bcru Sckolat stfiil F!B${ri K$lmhrirn uru Kdrrl Jibffii d$r Pegrnrs Sy*iirrt :

Cenlfication h! tehao( Privlpal / Head lfaster o? Mtntnry Mdal or lkd tfiessmnt or Corpaqy ynwgrr 7

Saya mcngcstlkan maklur:mt png dibcdkm oldhp*rroholr fada prngplahusn ra'i ddah boo*t dm rcpat
I carr(y lhal tht t4formdttottgtven by ilE aplicgfll*w lln btst of *tybt'lutlcdpc la WE endtt lr7lcl

lrgrrrn / i!'bme I IawEb{ /Port I

Alailat PcJsbnr / Officz Addren t

AfiontSwnp

lclefon i Telephone:

f rikh i Date : Tanrtufengrn /FJfaafit?;

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FORANG PERMOTISNAN
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ftograrn: Kad I Cade Nrma Prolrrun darp. la${np / Jvane al Progrdnne in fitll
Fragr6nme :
Fillhat Prname I r:TT:
First Ch+in
Pilihan Kcduq
kcoad Cholct
/ rTI]
T,qlron,{kadcrnik I lcddqotie lear :

EAnaclAtr/s4glfitryA
suTs-uJrr$.xllFrBAnl I PE{$o.lv4# osl4Jrrs

l. NErnA Pcnuh / Fvll Naae : I

Geiil6,1/ ftrld :
(A$s / Dyg I Mr,/ Mdn / itrs / lls)

2. Eil.l6ad Fcngcnrlan / r
ldatiry Card No, :
Warna/catoxr I*J Y-Kuolng/YcUon,
R-Ungu /Purpl*
G -Hijau /Crcm
O-Laln-Lain / Othcrs

3. Ean8sa i Roce d. Ugilna/ &lrgloD 5. lantins/Sr 6 TgrdKi{rmh / ilirritfll.ltaar

lvf 'l*lalif Male n SI'Euiurg/Singtr

f
F*percnrFuur/Ferot fl MA-ltahwirr IMarricd n
OT-Lain-L;rin/ Otlrezs n

?. Bir. P*port / PersPorl No' i t, Ksrdqntan I Cltlza'aship:

Tarikft Dilaluarlcan

T$tkh Mensuh I Date of

-fcnrpar
Dikeluarka+
I p616 6! [3sue:

I
ffiry
Place of Is.ruz:
: ffiffiffi 9. i{0, Sijil f.qdqnun 0ikr berkcn$en)
Ckin,,:hp Cefiifrcats No. ftf qplieable)

10. Tarlkh Lshir I Dale 6f Bh th I

Tcrnpot dan Neg*i

Plall' frnd Cat$lry
dllaldrku /
of Birth '.
rnmm

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I
A dfurs s i

Kod Pcl i Pgsl -fode : Kod Fx / Po.ct "Corb:

Ttleforr,r
ru filrphon+' - il I
lelr,fan i Talzphonc'.
iil'rlruIrn
Fars/Fff, m]] - l I il Tclsfon Ehrbit /

t&us
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Alnnrrr F-Mcl/Fir'ail ;

13, Orrnl lVlsdrh Dlhubungl/$rudrm Ttrtlstret Cilmr !* Alamrt) lluburrgrn/ftgla,iaarn,p

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Contatt Flrton / NN of Xttt (Nanw & Addrctsl
){ana / Abne r Prl* E$r / Fcthar tfu- Suamil lilstund
MO-lbul^t{orher Wf - btcri/ r{frl
&U * FBrjrgB/ Crdrd,sil OT = LrlF-lf,|n / Orisru

Rumah ,'Hane I

Peinlttt / Qfice:

Tcbfort l{umafi
ItdnvTal. Na,
ul
Kod Pos i ?ast-Carie.
I
t
Tolcfm Pojabat
Ofilrl-TcL Na.
ilf
Pcrlrerjea* / Oectyatiol !
Fsks /frr ml
| 4, Srrnrb*r Bidyrsn I Soarce af Fundtng fI:
B{- Biasinrs K*ejaarr Enrnci rul$k wargansgilq $,6s11qi.! firv'r.l Gotumttlint *hoWthlpfor &r'll,neiChitan
gg * 61s5i5ut 8$P'untulr rpgfgmrcBgn Brudsi / Bn EI Shell Pef:ol|{$t$do. [ld. hholwthlpf* i,ranel Cituen
lF - Cuti Brl*ju.Dulam Negcri urnrk wargucaeeBruaei/ lr-,5arvic t,$wtty l*;rte far Erune i Cilirsu
I$'= turi Tidrk Bsrg{i Dalam Ncgpri rlntrk.{'srEpncp* nrunci I fndtmiss-Sblldy Led,qc lfithout Payfor frrunql Citi:en
lC- Syarikar Swasta/ Prfiare Comparq
PS * $ckolalr $wruu / Pttva!€ S*?al
PO-Pqfitulan SwasuY*ng 146 J Ailur fnl:att ft*nn&*tlory
pS - Biilyaan Pencndirlan / Pr iv6te S$dcN (Stl:Spol'{oftd)
O'f =Laln-tain / Orhcrs

, drlrlr pcmbiny an I Is finatce prdttrilnsl ar confva ed?

Namr rtrn alan* orang p4ctndirhn atau orgnni+eri yrngnu nblgyil Patt&iiEn?
Nama and t Qntact adius o{p*rton or ltgwhdrionrcgustblefar ryykgyur feu?
Nanta / #cue

lJrrr,at l.{d{&.rs -

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15r- FiyurJron samo ada panralr mencrlms Uiarislr? krnjun Negarr Bnrnci Danrssela umuk berhrrrcus di y . ya i l.er f,
ilil'fi:H::|b*no**drdaowrrunentoflrunathnsatsnschotanhipattr*rtostedy
N'TidakrNo ft
locally or overseas

iika sda sile nyrnlan I llyez ple*w *ale

Kapurusrn
Tcrnpoh l{utos I Dt$'at ton
Narnr Progrant Narn$ lnsdtusi daB Negsri Resdt

.\'ame aJ'Progrcmme Ndrils ol Institulon andCou"tt)/ D$l Eiaegs tr:lus / Oagsl

Frdn T6 Past / Fail

isilr ssrrakan sdinrrr $urat dari Kalcnredm / Iabaen / ASaili be*cnnan jila awdapqnatr dtbtnl*gt Fcn3anuggahan
blasiwr kcrqiran tlcgua Bruncl derrrularn /A8tqtsl b.*inrir 1 ,

I5b. Maknjr awda Jugo mernohsn 8ilsiswn Kanjaan Bnmci Dontrg+hm whkroelurjt*lon pelajrran ke luar negcri pnda Fhun iai?

ITavr lov alto appltedjcr governrrew rcholatshipfpt owrlr'ar slrd;'lhisfiar?

Jika e4t, nyathkti. I lfps, ple*se slue.

(ii Tnrikh Pcrrnohonrn: (rl) I'lrmr fupfralt ;

Datr oI applirdtton: Nane qfProgmnne:

(iii) Namr lrutl$tsi (rY) N.Bnf ;

Naae a! lnstltutiott : ConnoT.'

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BAtrAGIA}I / SECAXON D
IiEtULUSAN'KELULIISAN LAIN (Sijit fingfl Kclrulr$n , Dlplom / IJrah Frruffir / Ifrrb BuJror)
ltCAnEfrtIC QIIALIflCAilIONS $IEha NrdlqndCcrlllcda lNSloilElFlfti nqftt / Irtagr€E Dcttu)

Tcrnpoh fursul
l(qluluiEn Ngrrr lrudwgi, r,--gcri ctttatlon Itulsl/Ctld/Lulur /6€fd All'ln Pcrgrnlrf
Qttlifco:tw Insl.lptM Ndw, {tttrnlry 6,bx/Gvo*t Pass/ Faal lllllun of Language
Dai HlqsgF

fron To

If your higlrlst dcgroq wps r Mattcrs dqgrsc,I'lssc a$lwEr thr fnllowlng:

t. Dirl you *rttc * *cs:t If 1c*, plerc pmvi& ths lilli

2. Did 1ou rvdtc a scholuly rryonag, articlds, monogrqflr? If p+ ple*a povidc ihttltla end arUph copicg ofth6cartlclrJs,
monognpll/s,

If your hilhcst drgrr+ \yas e Barhclors drgrcc, dld you wrib 6rry lc*lemic c*rrris* il univirriry lcvel? lf yes, plcr*e prtvide titl* snd
padc obtainci.

f, rrAclhttt*ELTlorvc
untuk dltrl oltrh pcmohon tc6pntrn preprrkhldmrtrn E$tir I tN,, [d lllledtn hy local pyr.*er'ltte d?Pllcdtu en+l

Jikt beru flqnsmsiltl{ pengqJlan *ila nyaukm :

tfyou lw,te jast co]/is{IeIEdyout r$rdyplewa stau:
Nalnl Stkoiuhrkglr / lnrtirugi :
Ncn+ of tuhool / College I lttditatipn:
Taiun nertarno*llt ptagajian ;
YeardConplctingyoursndy' '|"-
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lar{uurt I .Plwre atcr,h Eoqits of'O' and 'l' l*t{ *nl$cttu
I Sr]r icn*ksrr $lirrnn s\iil psrirgkat btnsa dan J

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Bsharr Manulis Merdbgsr Fctc*ryn

Language llhluw Faadig Sp"ha

tsahasaMclayu /,Valay 3- $qrggr Erik, I F';;cellent

2-btlkl6ood
Inggeris / f-qirlh I - Eedrrhglra/ Fak

Bsrhsrs A.i.b i lrabic

,IilLr Lair" l'r'yal*an

If othtn , Pltwt State :

BAtrAGlt'l{J$rcrrdfff
PEN€ALAMAH KEEJA YANC I,ALIT I PAST I+'ONX.trPEITEJVCE'

N+maPtnagartl ErdEn Itr$:rr8$ dlpcgang

t'lanre o! A ts oc t afu t / fi odY Podllanhild

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1. Jsivs]an Sqkarffig / prgs64t Pcrt

1.. Tempat Bcrtugt"t I PIa.z ef Wark

l. Nama dan Alu.rnst Mqiik$ / Enwlayr'tNatne andAddm$

{, Tcrurgkmr huburtgkait Pro6xern ynng dipabofilgrndsrt6ill trgff nwdr,

Iw{icce lho re'lwawq of the prltgramnc{'t) Qplled{u lvynr currcnt d*,llss.

EAH^GIAN ISECTTANF
PFJNCAIJM^TIi KEFJA YANCT,ALIJ I FA{f WryNE EJrfSXIfIVCf

t'IflIns dsn nlamat majikart /

Inp! o1w k N ume nad,{drf,rers

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SJale thr recsonl loryour appliedtlon / E4laiatlru rclatiswfuP brwcsnyowJob andile yagrmne(Q qpliad

EAIIAGIAI{ I/ SF T'O/Y'
FEI{YE]I.IbIIilN DAN T{"ITEFETTA H
nx,sf/.frcH,thnpu'ac xloMs

l. Slln sifiaralkur pcnyalldiku y-arrg tclofi sclc*ri dirr pcncrbiFtL jikn adc
Pltase {ist comFlettd rrseaz:ch endpubllcotfow, If arl

2. Siia nyahhn bidurg pcogrjian /log diEd&?dffr I Plealn ldtcakFaryedfnld dsndy :

i, Triutr; Penyrlidikan /-Rgearcf fopic I

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l. Silahrrikandulnamadan6lbrualorsngtmgbolohdirujukurtukmcudoprtprlfiponn*rdernif
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(iJ Nsms i,\'ang :

Jrwarur lost:

Nilnal I lddlr'r, :

I clclon / ldt i Far : E.Mail:

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(ii) Nsma /.\'arre r

Jawrury' Fr,'sr,'

A.len[r / lddr'rr.r ,'

Tclelon / fel : Fax: .- I

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APPLICATTCIN FORM
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Prufnrn : r$lr,dl &&

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l&nh'ty Cun No. :
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llibuhlngi / $.r:drl
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Naflre allilrlltulton : Cww:

16, Arirlstau,dr:cdangmory;knrir*cmrulmEilndiludursiFmgEjhnfEggi? Y * Yr/ltr n

,4tt yort qttatding atty pcde rttr, plgrsmu al laslitu:r' $tttlttr Efuctrllor. el tl* m&t errf? N - Ixtrk I lrlo f]
Jikr rdt, rib nyrlctfl I lfya, plru.:re eda
(i) Nrmr hcrgrnm / ilmc a/PnEntms :
-* --

(iil Trhu,n l'nflusJ}m lYtw d,l&nlsslon;

(iii) I'lo Fead*ltarln I Anpdstctlen ]'lo:

NyraLrn yus*ol&oo bE'sula d.Ii' prirgkrt ueaecaal trrr (ra.tilindt hdtih]d Ptng$in 1t4g)
Siaft ail tihtolu attcndeA *antAgxt tppg. wordry t-qvl {*hdtnglwtMa
af lttfurEtt',{Jztioa)

Kdilstu TtrtiugEi DipfrelEtti

Higha:t 8t dtli cl lin a O b aimd

28151
 BAEAGTAil/.ISCIIONC
SINLAId PBI-A.IABAN FEEINqKATMENS{CAII
s[iil Psl4irrrn Ugs$ Sruld ($,P.U.B) rsu ltrs s$ladiDg
(Nyaulcu Milr ?oh,sre yrqg luls $hjr)
GETTEML CENNFIdJ.IT Of EDUC&II(N:
84il rr/q,aran tlgana trazei (E.P'U,8J w e4nvala
$tatp subjec* thatyaalwwPttd w$)

SUIL Ah,t PH,AJAXAN PENb$EAT MENENdAII eu png rcbrsrding

Ofyrrrbu lvlmr ldajarm vuf lnbx sti{ia}
6ENER4L CEEITFICAIE OF EDUAMN 'A'LEY&LuI eEthvlwtr
(frat rlahlaas tha Pu lw:m PdsvA wlY)

Mltrpdqirran iorcdl Altorl

*Q,tj6ct iGradcl Mgdglt

r._*.-
I

' Sllr gunrkr+ Iod rujukn rurupt{mn yug dbcdia}ct

liccrc u.rc nu\l'ss l* co dts Pw,.fud

-4.

29151
 i\0 llli P, 23'4i
/'

nAgACIAn i,tf{Tl6JVt}
$IIIL PELTIARAN PERINOK.S.I TANJI,ITAN;
Sljll TingSi Pclajafln Uqnst Brcd (S,T"P.U.B) orrll v&U tchnding
Ff'rdrnn Mna Pqkirr;s ]eg lutuc schjg)
oEI,rERlI CfiftnFirlTg aF ELluctTIONI
Stj il litn*gt P dqj ErM llgas Snngl (E.t'P.U B) at qdwl ax
1fiau rttl$ent tltrt F t fus P*.."#d aft$)

SUTLFBLAIARAI{ FBBII{S{ilT t^A}fiilt4H ilm yart$ **il{tdlt1e

$+y&tr&rn t{ffi FFlqF u yals lsh}t iltt{r)
GE N EtulL cF,&nE;rJlffr OF EDU(fi[&{ N' IAYEL or tqutv alm't
t$dt rabi Ecfi lltat Wu haut Wged odY)

Fdur ltrFsihtflilt
filotthaillailtrlcdr.

' Sitr gunrkel kod nrjilkun iltilp{l{j$rn ynng dbcdiakm.

Pleslc tl.:re tublerts cpder ptrvjr&/

.5^

30/51
 i),(. hJ tr,6 2 65'22;g ll'a
llu r'rnl
i J) t l, 2i 4!
/'
EAIIACIAII /.IEE?ION E
I€LULUSAN-KS,ULUSAN LAIN ($ijil Tirgi KcturEFun J Diplomr / Xsrur,{nr / Manihlrci)
OnHnF, StllUFICATl0l{s (Illdltt N'ltio7p,l C&qnfrfc / Etpluw / Powtd#.btt Coerst / &lotrk;/,latidn)

tid$/S$d/ t$lu/ 0url

I x.tut**' Nuo* h*iHel Ncgsri
IwnntisnNawt CoUrtr'] tbtlGr&lF,lrl?grll
lfuafrcato"t

r-t
E,+FACIAIt lsBctIU{ F
KEMA}ITRA}I BAHASAd IT&\T'UI GE FRQFTCIENCY

Bahrlr
Ianqwge

BohurMehyu/ Maloy t'_l I - $m*r:Br*/-&ddua4t

Ingtrir / Fngliri l1 l=
1=
Brik/Gmd
Erdntrlrl.Fsrt
Bdug.t Anb i drtrbic
il
J{ln I*ia. $irr Nyat*hrn
I/?thu* PloasdS/ztf I

gilrny,rhkrn kepun$rf / rlsr B*hm.r lo$er;r yrrgdiFfltsbbi ddrap4aibrra /ujirnbaihtjikrrdr

iWi trao turi nntttot Langury.eru:uir/ rcr/il46tqhsd lilIl*{fuviw ca nlnatun /w
({tw)

iotrfl. '9cong
ffiar-J l$llS,soqlr ffoar_'-.-J
Othu 1"ut (fuor-)
Sitr rcntknn mlimn kcprtrOFr pqcril}fin /qiian yWg ttrclrrtdi $r' Yltrg t m dilrfi&rs'
F|sdlle ottttch a orrtt!?ul aayy aj n cabord trdtilittnd,rfll t€d ftt ih.

31151
 /'

FAS.{el,rNl8fffroilc
KFfi I,ATAN tU.lN DAN'{EA}ILIAN DALI}d PEilSATIJAN /
ETTTs]-g TRRICULUM AffIYMN /lI{D'NUDEFAIj/N N T$TWUTTON

l. Altivrd $d.|ndan Pcrnru /fraru adQaneyActi:'/Ita

lenir AHiviti $uloa / funnriglr llliq6f* F.otLtr*tm (*pqrU prr.*uu" dsenh, nisi$rul)
'llpt afSpo* / fua Aeth.ltltt IErd uIP&lldpdttw, (q. Club, Dar,lda, Nartmd)

2. Arriviti Krbudryr'qKcrcnirl&Klridmath&qrralullal,€Htl,'sttctitii.tfttamffiElt|s.,t*at

Jmir,l.ktiviti Fcdftffltnsssllh.lnrt
Tyy* atAettvtleg f*vl alFodlclpllan

3. KerblimdrtroPctrrhU.ndnnEldrt-ba&sllkhtt!illt&EfrthllqliJclfrldflflIairdnr!|fittlo*,tlnlEildlj5

&r&ArdYiri
rypet o!,tctivttla

4. Iicgrrolrrs I tr{p}bIPJ

32151
 (Balrgiu H &tt I urtuir rliirjlm ol&pamahon ltng rdffX b*ttF $lqri)
(Seeian I{ and I an to k fitted in fo rwtttury ry11s11 qsfu)

n llL{GtA!{ /.T8f.ffoff r
PEKERIAAN SBILI&,TNG / PfiS$'8HI' OCTUP,ITION

t. jawrtr''r Sckrnag/ Prt',rnt FpJf

)- Tc*ryu Brrtugrt I Pl*e of Ft*

l. Nanra dan Alrutt !.{4iikm i Englopr t Nais atd A#us

Tctmglcn hubun6lott Ptojrtnr $ng dipoh0diln dtq$4 tltgl! r$dr.

lndiwt t tfua wlcttaw o! tfu pmgmmt*(s) qplltd /or t0 r,ur unrwil &rte*

BallAorAr{ I gg{.7rol!I r
PSI'?OAI"AMAN KBRIA YA}TG LALU I ffT FOfitr{FTilEIICN

Ihrilh /
D*.ret
Nuinadrodrmltsqilon I Jc.*ilil/
Employ er I{ aav aPC,{rlsrYet t+sr
b Hinst$/
th

I
-_l
I

-8-

33/51
2r
j. l'" i''i| iliii ii,l g$'; ? 6ii??80 * :,
--
r,,t(i
iilj 1? 4(i

/'

uo^**r**onj
Atv'lGElJEf'tL

L Adarrh awdr pornnh didryod bssnlin dahm mdrr*.E h! ralilrtrh ? (3ih r9ffekm' jtra Uetmut)
Ifw ws ln'w bccn cotnrard ln ony cswl ol law? (Glve d{tnlh { WlrE&leJ

l. gilabcrtkrndrlrrl.EFddrnattruncmryyrngbolehaiqiurrmnrrnanlaUrnhnmrn*adsnih,
Giv th naner and atr#tiss af tt"o nftr*r to wtt+tt $aure wry h w* an yow *Mt mard.

{ij Nrnr i l{arrre.

Jrpah$ I Port :

Alrrar/ld*t.t.'

Tctaf,oal fel,' Frx r E-Mril I

(ii)Nrnr ill*mr.'

Jrwnn/Pasl,'

Aluo*t /l*{rer,c:

Tclrfotl Ibl,' frx l &l'ldl r

34151
 '; r"I \
1. I I i l, i-'0 96fi ? 65122$E r'l0 1t37 )) +'l

Dafl,rcl t{/gEctlolrfx
PENGAKU.TN/DEd.ARANOH

I Brh$yr dopr lerungnbnyr eryr neryrhr suur wlhtnrt pag iilErilrn ddrn b{sd dm bax. $ryr brrt€ttju ttrn
mrm5lrmtrn ft6psa[pi]*kUniwfltilderu S.ttm Shldf'r{i rc,Inrnyrdr pcttbrhilrrtr$pefigniirnrrya di Uniwrfi
Islrm $ulh[ Slufif ' li. Slyn jugr rserltts luh*rr thivmiti lttfi! Sulttr Sbdf 'AJi bfftuk qfi* rucngubr! rur
mencrft brlik scbmrrg *o;mure mc4tend karr*la rlF 16 U!iy6{'stli hhur Sulan S}rrif 'A[ Jitr rur&iunilt yrrg
dihrltrn rdrkl tidak bctuldft li&t brtrlr
t ltt*by ceftW tha, otl lhs i1s.tfltottar, pr1tffi by nc iz cofter,l etd !t:lrt. t ognc * lnfonn Uniwwili Islan fuilrn. 9w{
'AIl iltlats uts, clunge*hila I w il:ldyirrga lkltctilfiftlstn&Italtfita{illr.Iaboca{ttfut Uniw'l'ililtldrt.SlJtrlt
Shotl'Attrucr*t fherlgfula vwlt or rcvasc arytdtttt*xpton-ugt6167 r*lxiuinuUntvcntal khofubn Srar{'ffi
lr{ rht fnfomatian Eivltr b ldla,rrte! awl utfuva,

Ttrikh /Pdlr:

Z, pct&esehmohhPergelua/6wu8orrr$dobb.muFcglilililtumc[tcrirnrbrl(mslrbrt'Estll]fiSEruESyadlat:
n;iftrlrtan hy Schaal ftirroipal / ttead Maw ar L0nhry Ofllclal * Ileod o{&pr*mrl a/ Coa.1any trdowger:

Sayr mcngor&tnn rnatlun* yl4 dlhrikrt oleh panobon Fadt pir{Fftl$m l*yr idrtdl bctul dln bciltf,
! ietllfu that the infornotion Etwt fu IhF appllcattt to fix 6ert otrry frrrd@ & curn cl ond frrlg,'

Ntn.l/ Hw:
'lPib!/Patl"

,{lltE.|t Pdrbir / OJti *,lddrcw ;

Alannt E.Mel / d-Lfail

Tcltfon / Ielrp,loae I
Ad&v* :
;
E
T*rikh i Datc lhdnrnBro /,Slpatrrr

- t0.

35i51
 ilt: rSil P 2441
a'

R,{ITAGIAI{ THI IINTTIK IIIISTK*}I O[,SH FAIflN,fT / IN$TITUT

rtl,t sEc?]#il 15 Iv EE f tuED N Ey FeCWn / NSlt',tUrc

Nrm*lqnohos:
lppiitau! Nomt :

Ilognm Dpohorhm:
lls g7s1ap1 t'l p pl( rd /nr :

Kf,prhlriu Ptraohonrn :

,4plirotion llala? :

t.ryrtunrukdilsrNdusp i-l ginTqnsn

f-1 niewfn4l_l Uotat i -l tey*rum*tlxi Qirobrurlir
Qialifirtforanhta-dcwL.. I Roitrr t-) Wad I I e4r'dttod L-:j Qulfid,iprilfllagar'fimttlr. I I

Scbrbreb$ drtoltk t Rqaosorl,r lu' cctn? Hl4rtd:

Nrrna Po:lrr / ,{,ls er'r.or's Nalna :

lln&hngpr I .tkndt dE j Trdlh/4atr: lr

K(Furul"rn S1lc1:as Tarnrdugn i UjirD FBltulis | fuilt ttfrr tha Intaatffl / trtlfiF/t Itut

Ditrwa,&.ur/ Wrrd n
L-i
lti$hk/fi4ttt'rd

Sobrb+*sb ditolak 1 Jter+nru/or \cing r{esfil ;

lrhc Psnyc Isrtl Panrl 1'e1guduge / Ujinn Dundit / lfanre af Cwt*nnr htvvk* I Yrltlen TNt Fonl :

Turdrur$sr/5lgmilru ; Tnrth/DaC;

- rt..

36/51
 I'iC ' 1l i F, 1Ft 4l
, EL::-:-i---L:-:- - --'

IWTUIC KEGTfXAAI\' UT{I8SA SAUAJA

Ditcmal ql?h:

Dinu$ub{ drl$n kornputcrohh :

r-.-1
K+uurre$ ;
L] SitrrPm
1_j
iloold( l[J

$T fiiSFEMOUOH
t, rrngarr ditxrlrknr:
t]]
?. Ha liul Pmguulu r Wr6e: Tlnllr[.]$r:
--
3. ri+uhrrs.o PcFlkrsnr ; Bahri{ Mclryu Puringhl nirn (B€CE'O' lwd) - @d J* Trhn
Brturr hggcttt Ps.:indttt Fi*r (6GCE'O' hml) . ffi Iltnn
ttiu
---=_
Knlm Aur (Caranl ?F) Fcrln$rt rry^cm (SffCt'# I6r'!n - 6red .-* Tbfun
.I8IJ -
IE;[SOvcrdlBF'd 6.0
lJ
4. SrrJut Dltam*r4: i) Buiicffi Kffqjo.! n
rJ n) EiqAan Psrrttdi rtu (Fss f ryins)
5€b{hrcbrh Bi4ilr.rr pasfi rdirin
r) Bukrct*tnqt
t:
b) lidrk dt dlgtrrryrl h&rhro:
ErI** h{ilrnr pninggil Hisr
I
rrAas tuggirP*ftgf$hinr n
ttrtt

- ttrr.rrAr?tpcfutrtkiffin il
rts
IFLTS OvEfill Bttrd 5,0
n
n
In
o) Mcrohooutut mcrnbirlai *ndhi p{nEdi$t dl UfIl$$A

d) fcmrb dlruildtru birrisll,r lsajtm nbeiln inl.

c) Dtbiayri abt Filtr&sw*la

irfuss 5r1utr I

iii; Cuti Bclqrs Drluo UeEfit i$Fdy t.*rvl) v) fttt T5dah Esg{i Drhr" Hagsi
Crtrtlr:

-12-

37151
 m
")
l+ il(l t()(} 2 6t1223t 41'l
r
l.)),1 4t,

f,{r{,nfl*s#eiloffilhh
Ul'IMntm ISLAil $Uf,TAF{ SHAAIB AU
SULTAN SI{AITF Ail TS!.$MTCU|{IVBFSN'g

F$RSSO sF,UAEtrK*fi
{aFf;UC,AffiOtr''OAH'

PR$ON"EM I.IAfrAII FERTA}ilA

rfiRsf .uE{lEEE Pno{}Rail!ffi$/l

Slln Lsrbslitsrborqrg yrng hlnh larql,Ap dib&* ircrranr

dolumen yang clah dinl*,rnkapadru,

Pkwe wtunt @Et l$rw WflE wilt mtifitd wpra o!

rt+wrLlfurfl''',ttt,,|.

rcnikfiar
TkcF4formr
Univcdti ldarn $ufhr $h*rif 'Ni
talanPar*tBahanr
GrdorgEEl$10
';i lilegare Brunc& Drrus*fiI*n

frttlfto OFnfi , FtE rtmatr,ltFod

:*l

+ tr [i*E!'t*ri t{.d'Frt }.rt*g

ft,Fl.rff|h6ir.*l!.n

38/51
r: '' , . ';' iL i,;ii l',0 9()6 2 6i1il2,i9 Nrr, 1ji7
:

BORANG PERMOHONAN
(Program [irztrh Fertama) tdcr*ll
Gcmb*rljkrnn
A}'PLICATTON FOR}W Plsport di rini/
(F iv s t D cgre e h ogr amwes) ,ltl*h Pasport tbt
, Phudg?agh

[.*,
l$esi / --l
_ !
herc

Profnrrr Diplom '. Ko4lCo& Nillrl koglun ilttrgfii ltntjrqp l Nsrtrc af hvgrlstw t lul

Trbrur Ahrdami& / Ac"dmh Year :

I NaroePerqh /FFlllfdne.'

6ohs17f,Ir&.'
(A*g /$'g ii!!r: lb{drr,lldts. ftrtt)

?. Bll. ttrd Pen$nNlED I

Identity CafiNo.: tt P -Urgt/Ptlople
O - trijr.u/6rn
O - fr,h-L*hi otl+rr

3. Blrpa/ Raca 4 U6eruE //frl{groa 5. l'fldru/.fs 6- frnf Kslroin / Lh$tal Erauu

M=Let*irr,rale I il -Sr ==BuJcag/$Insr'

Eujcqs/srnl{, n

F *farqpxn/Ii?tr]n | *- Krlqio
ldA. Krhvio/I{odedil
l,.l{or.r'*d
n
I
0T - tsk,Lai,oi a,trrs[J

?, BiL Pligpfll / F6isPor. No. ;

'rirritirDilrqrurtkn I-n fTl [n

tDmdt'rtw: !, Nu $ijl lLentydrn (Iih b+rkenu /
Ciibcnth$ trllificue No, (;f rypl ic$h)
rs*hu!.Brub/DanofEtpiry, i:n E] n]
Tonp*lDrlelru,tkx|Pln+oflswt *-
". -
--
i 0, Tu&h l*ir i P ala a{Birth '",

Tempec drnNc6cri diJa"i*en /

FIun 4'd Cotntrl <rf Billh t

39/51
 [lf',111']
tr'..t. l)Jl n -j:, Ll
^^
f.
i,

ll. Ahmrr Pcrruurnl (arrcspondt,mAM"* N*toa I

'lppliwtt! Pmwast Addat
, 12, Alrmat Tcup P :

Kod Fos i ^Pasr-CodE; Kod ?og/Igrt{rdr ;

rcreroa/ ntephonc :lfi f-mi-[fT] Telofnt I Tclephone :

m-
Fels;'F& tll^frum-, f] [hrqnuimoir/iebth?Hryrd'.,1f-ifnT[n
Alnnd E-&{rtl / E-^l/n l1 l&*w :

I3. Ora4 lrludrl SbilbilnBj / S0udf.i* Tadrkrt (l'furo* &AIUut) ll+bungln i ftolalirnrltp ;
tbnrau Ptrton / N6rt af Kin (|'lann &.AMrcss)

n-Ung I llirne .. FA .Bapa/Fd,Dr llU -Sruunillfipbarl

Mo-lbrr/l/*lrs wP ' IsE i/ Frf,
0U =Paqhn/firrdol OT r lrb-kln/Orrerc
Aualf,h / ffemr;

Pcjabati Qdicc.' T:lcfmRmrb

Harl.ttcl.Na rn
Tcl6lorFqirb{l
QflxTd,t*.
lelt{coBinbh/
fn
M$lhlH4hane:
Xi'dFo:i Po.rr
L.ffi[
It crkr*jaru, I
"oro,

Orn:pallnn :
F.k{ /Fcr

AiFn(3&ftil /tr-ilit
rrl
iddr*t,'

ld. sllr rnnda.krn Suarbcr Birgrm / Flcat€ trtbaft 9ltrr qfflnabur

tll
BC- Fhsfuw.KffrJ*'.nBrurrei rru*wr{furrgurBrunciJ}nrtefc*verflrr}eflr9r,bol*tl*pformnd{ltfrcn
B$ - Elr$*wr BSP unruk vargrnamr. Hnnni /Jvr*el $ieD Fnftleufi ,S*h Eld, sdnlrarrl*pfor8nnat &tzca
IF - Cuti Bolrjrrhlqm Noferi Iln ScrviarJtvdtrcam
fW = Ard Tidrk Berydii Drlffn t'LFEti /.lx*frrvr*,$rfl Ltdw Wilhrn Pry
PC - Syuikrr $wa*n I Prtvd. tclt'pany
PS - Sctohh Swrrtr I Prwile Sdr.ol
PO - Psruhilrrn $wmuYrng lrin I o.lgt PNvaE Waliltation
$S o Bir).pn Pcmrndirirn /.Pt"tvat Snulalt (Stlt-Vorsc&)
0'T- Lriq-trin/Or}er.r
Jfu $larikrt / S*olU / Ss'r*tr / Orgsd.rrsi rtru hirg rtlanyrrnkrn uomys
lf prjlslt co,apany / w\oo1 / ortld',kdion w ofttt, Fksra ret IE ilattf.:

Airalr /ldnhs:.'

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41151
 1,
I tI ijri tr0 t66 2 65122$E' lr0 1lii I, Li I')

I5r, Nyatr-kan srrna idr peraeh rnincrira birsiswr kcnjrroNrpnBnnoi tmgrlsnr y = ytl yq
t
Statt lfyau hm,e cv* bnt swo*ld Gownnant albntwl Dttua/rilM &holf,:{hF
N. Tidaklffo I
J*r rd4 rilE nyala}tr,n / ][yes, pls$s gta'p.

Tcnpob Xursll kpurrlart

)lamr Progrrm Nr,le lnstihl"ti dan Negeri Dwr dioa Rcru{t

Nanr of Fmgrawna ftuac atlatintlon a*l Cawuy D$i 4bm brluc/Grgd

Ftt'rn n Patt / Fail

t $ils scdakm saliusr surr &ri !{snadlorun / Jab*rn I Ag:nri fakararn jikr rvda pcmrfi diumttro tcdEanuSe*hril
biarisua kcnjrur Ncgan Ennci Dguurbm /A8crni bcdteolrs l
l-(b. AdrttrhEwibjugaoanohotBhcirwrKrr.jraoBn*iDurrnrltnunruknrchnju&uplajumkalurrnr6edpedr
nhunini?
tlavt 1ou ako appl tcd ior gov*rzatear tciolrilzip for @rrtLgg rato' thir )4&l
Jikr rdr, ritr ny-rlrkau/ {[rll. f lta* $atz

(i) Taf*I Pamohomn: tli) NrEuFro[lrsl

Dnte oiapplfuntior : ;!6s{fmgrwna:
(iii) l'{rillrtrtilJsj
Nute ollnctltutton :

16, AdldishrwdrredurgnaglkudsobarrrrgprogrlutflIndihrriPonpJir'rturggi? Y- Yr/Yrr tr

,1ff yda attmdlqg ary uadtt,tle progmnnt 0t lmtiurc {fllElw Edwntlon er du naneat? N ' Tli* / rYt u
Jrkr arlr. Eila ty^lakrr,l lfy6, pleaie gE re

(i) Nartt Pmgtrnr /ilanrr o/hvgatnma :

{ii) Trlult Ksmasqk$ } YtoafAdad*ion,

(iii) ]{o Pendcfk$s I F.4ltlrdti.lnNo:

NyrUtcflr p{frakol|lm lcrouh dwi pwinglat noreqA rrrr (trrmsuk lDfitit$l Pmidilqd fiFfgi)
Stde dl rchsols attcndedtu11ingda. vfur won&rytaut lktlrttlttgfictlpc@/ ,t dtrEfucrxtoq)
Nmrr &kolah / Institrlti HhSe ' I(dulusm1aduggiDiFmltht
Nane o! $ hot I I h4 Ndrtion Io l{ehat fuaWrcatoaQbntud

41151
 IJ l;(l rl,t 966 2 (,i122i3 N(i. 1137 P. 4i; u)

EABAQI,IN/.IEF'F{WC
SIIIL AM FEI-AJ.r{IAN PERR-gf,AT !'{SNEI'IGAH:
SUil P6l4jerfl Ugemr Eruei (3,F,U.8) rrilytlg $baldittg
O.lyat*s [t*r 8d$rns ;rog hl$ snqir)
GNE R N. CE KTIN ATT O F EDUC,$ AN:
SiTl Palsuan tlgann Ennet (EP.U'E) or qtlvalent
(Et d e sab| a'ts *ut I m ls;s pas${ t t$y)

crcd i lina
crude I ltutnt,

SUIL A.1.,{ PELAIARAN PERINOKAT MilF{CIAH shr ytls $cbmdh8

(Flyrutu Maf ?olaiurn yrlg tulttt c*rjr)
GENELAL &sruFIci^TE oF EDllc*rION'O'- Lil?EL or qurvawt
(Slnre cu bi e;cs rtd yev har< parl;ed otily)

Sllr guulrn kod rujukrn rnar*peqi$* ylrrg di*dirhq

'
P/.dre src rubiedrs ca&sPrwldvd

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BAEACTAN/'fgfftOrY,
SUIL TET"{'ARAN PERI}IGKAT L,$IJ{JTAI'I:
$ij i I r'es'*y.mlmf,ffi;XY#Hiff s'"o"'
AENEML CEEIIFICITrc AF EDU AT TON:
StJtl Tinggf Peldsst Agou or eqalvsleat
Brmzt (S,TAU-V)
Sute sublcct rlnt yor.hincpwcdbzg)

Itslco*l s;q; o*'tmttan*t

icra, luai*l
tl
-T--T--- r rT
ltlt_t

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_-_-
SI'IL PSLAJAnAN PERINGI(AT LANIUTAN xtu I'ng i{bnrding

oror r" #ffiSHiBffid;ry,?ffi'- eqnvdr','t

(Statc wbj *B tAor yar haw pwcd onlY)

;d.
l'col ,Slar.cr lora"l
ca" I l&d'wn | tunirtlrrafrontrt

-r---T---- ttT
*-i-ll.l,.
ll_1.-i'
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Silr guakrn tod ruju*rn tnitaPclrirnn F$g ditcdtrtsn
Fhzl,c we ndfacl'r co/* p,avldcd

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BAH.IGIAN/,gBcftoflr
KELULUSAN-K.ELULUS${ Lttrl (suil lirysi KEb3ntFN{[ / Diplonr / f,unn*Aru I }lmilsdrsi)
OTKEI QUAUfiATIOI,IS (Htgtu Natiortal C*t$can / D$lonn / Fotdatilm @anc / Maria{*ion)

Kelulug-n Nr-rB! In5tih$! Nogtri Xd$r 0trd/IilhJi/ftfrrl

Qtall.ilcatlotw I m t iw ttan N atnc, Cotajry C,lorl/&&lPct/Fail

BAEAGIAN /''BCTlr'/Vr
K-El./Uil{lRAt't BAHA$A i 6AYO UIGE ffiOFICIENC!

Srhlsr , Moulb Mrnbrcr rombpcn

Il'nguott I wriutn Rlldrtag &shtt

Brbau Mclayr / r{/o/ey

lnggcrr* / Englit r
n
ll
lI;"**r;
ir-n*loml I

H llassdsbmrrat *l
Brhrsr A.rgb I lrs,lic
E H
Jilr Lria 9ilt Nyatrlua
VQIh.rr, Pkasc $late I

n
LJ E E
Silr npr*an t4u1u"* 71p6yp:hao IuSEodiliEt dryallcbi.dIhBtsScdflr!| / ujtuledo*jllcr dr
itii.l$otuw;tugilrllaryury,truutt/'corvqimi'ru/h tlplvllowhts#g'tl/tuslontrg.l(Vry)
TAEFLfxtp- ftter-) IIrntsaorr, '___*(lhat-)
Othcr Ttst

$ih rlnrken salindtl lFFril8il pcacdk*m / lji"to yul lfficbut di rtri

Ebh dir8hJgtr'
Fl,rrrr dttr, rt <, ccffitd *py attht &ave g,artlna$otrl/3sf lE rdf, ''!&B

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E$IACIrt{r.fBGtIOJVC
KECIA TA}I IUAR DAI.I KE^HLIAN DAT-A.M PEfSATUAN /
FXTEA-CWRICWUM rcHWNH lND MEN,fiER$Ifr IN AAIOCIAIION

l . A_kriviri $uksn db pr.rfi ilgr1 l Sportl tt;d Gan* Activltiat

,qnis Aktiviti Buhtr / Psnaiul Pa&Sltl Pfitlixtl! (iqctli ?Grt'tlro, &rn&, aeeionrlJ
Typa aJ5pru I Gmrrs Activities Lc*r/ ofFaftaion (q. &$, Dkuc* Naaoxd)

?. ,{hiviti Kobudayaan, Kcrcahr & Khifod ldsfrakat I itt, Qlwal Affid* & Cot tt ffilV Eaftrcrl.

1, Krdliandrln:nfat*truna-ltdm-bdapltlriss/lfrnfuthtpolAsloctatowai,hr;ft;$riailalEodlx

a. Koprorrrn i ffo&&Ier

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EAXAGHN/.TBCT\OI{J
AM /6EI'IEJLd,

l. Fcn:* didryati bcndnh drlrm nene'msr rurlrbmlr ? ($ilr nrtet-q jilgl bccharral
Ada&rb *rvdg
Ewt srv cver been convlckd ]n any cotnt of Lwt? (Gtve dcls:tt {qphcdble}

2 Sils brribor d$r uamr dra gluilt onng f'urgb{lct dbqi$k unafi mfurtlrn hpors ll'ulcoill
Givl thc nanu and oi,'tx aJ w nlete+t to wlf,Il. nfatnce ntily be w& on ywaca*ttlc
'tcanC'

(i) Nurr lNamt:

hrvaus / Post r

Alnmat / ldolurr ;

Telsfsn / ]n*l : Frx r EMrilr

(ii) I'I*rns / lfanrc :

t
Ir*rlrn /.Parl ;
I

Alun+t / rldlrtrs :

'lilcfoo i fil .'-- Frr: El\drit:

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EAIIAGIaNIf,ECTI0/Yf
TEHOAKUAN / DECI.AXAI?ON

Baltwa dagar reeulgguhnyls$r.mroglku *murndrtuncyugdibnihaladdrl bcal dubcrx,9oyabcncqiu *w

sFdqklum).rn krFrdrpihrk UldvcrrltiBlm $u[m$harif'Ai ctiranyr da pcrutrtu rllnrnpcngriirnrryr di t]aivarili
Iolrrq $ulua slndf 'Ali. Sqtr jryr r*rafdrn brheur Univaoiti liltn sulirn Sbuif 'Ati bc&tl wtu* mugubr& ruu
ng$srik brlik irborutg kctrttrctn nrugcnei klurnrltra gyr lo Utivsrsiti lden Sultr Shlrif 'AIi jiI$ nutlrset y'p1g
dircdhn {rhb ti&f bcrul d!CI ddaL bctrt.
I hcnhy canfi ilar all thc fr{ornafut plvldtd by ne b onvcl and rrllr., I qnc to ttfrn Uniwttll{ hlrrt Sultan sM!
'lli tjthatfu oty eltwqtwhll,' Iw rudytuq'at lJnivsttitihlafigultil&sif'llL I eltocarfr thdUnWtlhlmEulw
Sholf 'AIi rertmw fie dgltttovwT orTst2aawE dttlsk,npulfurttgtailrt M$k rteWiveryili ItW Evlta1l?f4{l'flJ
i/ the lnformatian gtven k itgort#]l d'tl wtttu*

TwiWl Dot. T8rdrrilgu Preoh w I lpplinttt Slgtroaat

f. PrujcflhroolcbFmgtua/SunrBesrr&koklrersuF,$wriKtnenlniorrhrKcero$tft&rullPcttgtrrul$yrdlol:
Cutiftotion by School Princlgat / Itaad llas* ar trrtnbtry Ofvtat orIhM alDqarnwt t htnptty trAryv:

Styrnotesrltrq mellumaryeng dibcdlm oleh pcrufron pdr pngrt*uDtr $Ir rfrkh beul df,tt bcd|f-
t cenlfy thar the nJonotiort gitcn hy tht apllcdnl to tha b*t af my hotdtfue i5 rlrratl. end t lta

Nrrnr i Hfifie I Jrunun / Poa.'

f'J6rnrrPojabar / Qlfrcu iddws i

Ahnrt E-Met I E-Mail Adthtss:

Telctnnl Tct*plnne,

Twikh / Da& Trudrwgu/JiPalwu

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B.{UA€IA!{ trq UNIUKI}U$IEA}T OIJEH rAlflI[Sl / ITYETTIUT

nTIIS XECTTON I8 XO TE FTIS,dO N 8Y &ICUW I O{gITft.ET

Nusn Pcmah,or:
,l.FPIIcanl S l{dn* .

hognrn Dipohonl^rn I

Frogronne,lpplbdlor t

lGpunxer ftroolcnen:
Applicdionhait:

l-ryrrunnrirdrranudugr I I sirp-""n l--l oit"t"tr-l-l n*ou f-l Lny.tred,td,kitdi:tsb.dulh

Q,alilicdhran,^..rvld+'. Reralc | [ $ad l) R{,tctetl I fiuslfuhrddd1gowrtttntan)

Stbrb-rcbrb ditolr! I Raraow ft belag r"tJEtld :

Nrynr Fmihi / &rrllgr i,1'cne .'

T.r&E^trgu / SfgTran/}" .' 'lhtilh/Oere.,

Dirvrq}mlAfcnd ouF*rr{loca ,l
Sr${b-t+bab .ribl* I Reosontfor bdlng tflattd

Nrma Peoyelurr Pmd Tcrnuftge i t{lan B*nrlls i iYar c dfuwdlrator latcnfrsp / ffiiltar Tttt Pal,d :

Trndrtragrn I $rg?tarrdrr .' Trrffi/Date.'

48151
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Ur{lIJK KIGUNAAJ{ UNI88A SAIIAJA

Di.u'trultr.[ dslun kouputrt oleh I

Dirdq's
n t,r**" f ,
o*t*,[

$TATTtsTEHOEO}I
L Prognm dirrarta :

1 NoXrd Pengcnelrn: Wrmr: Tr&htahir I

l. (quhu.rnfopcfuua: Bdn* Mchyu PcriDght Dirre (EOCts 'O' lcv60 - g$d Trllr! -.----...---.-.-----_
Bsh$E W8al$Mg}rt Firn (EGCB 'O'lcttD - Crcd=--_-_-* Tlhur
rbu
f."rbs A$ {G!ffid Prpc) F6{i$Sc$ b!j$*n F4CE 'if IwGD - CtI?d-- Trbllt
--

IEUIS Ownll Ernd 6.0

.{. sl3{ll.s Ditrwl{trn : i) OiasitsnKtrrhrc iil Bl*yrm Pc*oqdid*rr trfi Prying)

S*rb'rebrb Eiryrn prsrndirirn

c) Bulau lal6rut
n
b) Tt&lc maryuayri klluh*u
biur
r
n
Enbrsr Milayu perin8krt
ga!$* Iaggfflt f .hSla 8i{r n
stsJ

Katr Arr pstia€Irt trnjuan n

rt[u
n
mljfs 6vgdlBsd6,0
c) Menobon uook mcrnbiryri *odiri p6n[4iiflt

d) Pcrnd ditsrudh birsigr*r ks+irap $belura

dt

id
UNI$SA II
e) Dibiarsi olti P$rkt' 'tsu
Nrlnr rwutl:
n
iil) Crrti Bdrjar Ddrm Ncgiri (shdy t rw) v) Cnli fidrk Bag{i Dden Nc*sd

CcbH.[ t

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