SCHOLARSHIP APPLICATION FORM

Van Deventer-Mass Stichti

This form rvill be used as an input for a grant proposal AII the information has to be the latest data Please complete this form accordingly Incomplete forms will not be considered
Student Intake
Personel inforoetis'u
Periode 2012-2013

t\irm
Crendet

Your (standardized) identifi cation number

Emale

trfemale

Check the appropriate box Your name(s). Preferably first name and family (last)
name.

\eme Eird
dale

Your date of birth (dd/mm/yyyy) Your place

Bffirplaa

ofbirth

R"n
Sfet

The region from where you originate ("asli")

Street and house number where you live

Tonn
Postal code Phone

Torn

rvhere you live

Postal code ofplace and streel

Telephone number ofyour home Your hand phone nurnber (current hp no.)

Hp

Email

Your email address. This is needed for you to log in into the SAS and for the communication rvith the PiC and VDMS
Your bank name, to which the scholarship iq paid. E.g. BNI - please put your name exactly as same as your name in your bank account Your Account number at that bank Level ofyoureducation. Choose betrveen: 52, SMK or SMA Your TOEFL score,

Bank narr,e

Bank account

Level

S1,

D3,

TOEFL score

Put here your latcst photo, send it to your PIC as well.

Photo

Programs for manipulating photos are Photoshop Elements

(quite expensive), IrfanView (free) and GIMP (free).

Studv and Work

Plw
[s1E
fill in this spee sccurotel! Final examination expected date ( Sidang Skripsi )

sf ]'inal ppg

DaJe

ofToefl Exam

Write down your toefl instituion and when

General information Social activities (wirile you are in the university/coilege)

Write down your social and organization activities with the year of your activities and position in organization. For example: Volunteer of Environment-Go Green Indonesia organization (2007-present), Cummittee of Health Teeth
program for SD Cibadak (2007), Secretary

of

University Choir (2008)

Grant intake
Grant intake data
Current school year: Ilstitr.rte: Fa,;ul4':

Your year ofstudy in the requested period

(2nd,3d,4th,5th)

Institute's name Faculty name

Choose: UNIV: Universitas/university (S l, S2), ACAD: Akademi/ academy (D3), SMA: Sekolah Menengah Atas, SMK: Sekolah Menengah

ln$irute category-:

Kejuruan Discipline: Your discipline/major of study.

IPK at the beginnh-e

ofthe school

1'ear

Your IPK score at the start ofthe requested period. Put it in two decimals and use a decimal point (#.## Your sources of income. Example: Parents 40% School 20% Work 10% Scholarship 30%

Cofinanceis:

Familv and Financial Information

Father's Income /month Mother's Income/month
Rp. Rp.

Annual Income ofthe parenis through all sources:

Rp.
nake a circle on your mswer)
a

Ycur own income (if you are

Elorv do -vou go to

working)

Rp.

SchoollUniversity?

Public Transportation/ Motorcycle/ Car/ Walk. (Plere

on

\f ith n'hom

do you live?

Parents, Uncle/Aunt, Brother/Sister, AlonelBoarding house (Kos'ftosan ).(Pleme make

ctcle

you mswer)

How much is your monthly pocket money?

Rp.
is the cost per month?
Rp

Ifyou live in Boarding house(Kos-kosan) how much

Scholarshic/Financial Assistance/Loan etc.
Name of Scholarship / Financial Assistance / Loan

Total Ambunt Drarvn

F.d\fTT,Y ilIE}{BEFS
Name

Position in

Family

Single/l\{arrier

Education

Age *

Occupation & Name of

the place

of\l'ork

Note: if '.he

fmily nemb:r

already nrused away,

rrite u

R.I.P *

FORN{AL EDUCATION Schcol/Universify i'{ame

Period ofStudy (Start - End)

Grade in Previous Semesters: Academic Year IP Semester

lst

IP Semester

GPA,[PK

20... -20... 20... -20..

20... - 20 20... - 20
i.e: 2007-2008

SKILLS
Skill(s) Excellence Average
Less
Cornputer Excellence EI

English

Average

EI

Hereby I

certi!

that the informations above are true

20......

*(

*Full name and signed

DOCUMENTS TO BE DELIVERED
Piease enclose the below mentioned documents along with this application form and give

it to the PIC in your SchoolAJniversity.

Give a check mark M on each items in the box to support youi application completeness.

I )
J 4

A reference let'ier frcn Schooi/Universitv (Pr!ncipal/Rector/Dean) stating that you are a member of
a deprived

famill'

A copy of 1,'our ID card

(I(flI

and KTP)

tr tr

A copy of Family card membersiKartu Keluerga A copy of Bank Account

The latest Aesdemic Transcript (KIIS) *'ith the latest GPA(hdeks Prestasi Kumulatif -lPK)

u n
in

tr tr

An official income statement of the parents(both government and private) or your income statement 6 ifyou are working
1 Surat Keterangan
8 9

Kuraog }Iampu delivered by Lurah

please mention the job and average of the parents' income

If there's no olficial ilcome stetement

Sural Kei"rangon Kurang Photo

llanpu

deli,;ered b1'Lurah

fl

t0 A motivation letter Fith sbcii stoi)' about,vourself, your family, your school/university. Write about your motivation to appl]- for a scholarship and ebout what, ou expect irom it. Signed by you

tr tr

Signature Specimen Student Srgnature

Student Signature 2

Student Name:

Student Name:

University/Academy

University/Academy

v.5.vDN{S 2012