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                  Directorate of Islamic Higher Education
                  Directorate General of Islamic Education
                  Ministry of Religious Affairs
                  Jl. Lapangan Banteng Barat No. 3 - 4 Lt. 8 Jakarta Pusat
                  Telp. 021-3853449, 3812344, 3519734 Fax. 021- 34833981

                                           OVERSEAS SCHOLARSHIP
                                  FOR TEACHING AND ADMINISTRATIVE STAFF
                                       OF ISLAMIC HIGHER EDUCATION

FORM A (for S2/S3 full scholarship)                                                  Reg. Number:

A. PERSONAL DETAILS

        1. Full Name (capital letter)                 :

        2. Gender                                     :         Male                      Female
                                                                                                            (Click the arrow
       3. Place & date of birth                       :                                Date:                and pick the date)

       4. Home Address & Phone Number                 :                                               Rt.          Rw.
           Sub-District (kecamatan)                   :
           Regency (kabupaten/kota)                   :
           Province                                   :
           Post Code                                  :

           Home phone                                 :           -

       5. Cellular (Mobile Phone) Number              :

       6. E-mail address                              :

       7. Marital status:                             :         Married                   Single

       8. Spouse's occupation                         :

       9. Home institution                            :

           Type of institution                         :

           Faculty/Department                         :

           Field of Study                             :

      10. Employer ID Number (NIP/NIY)                :

      11. Rank (golongan)                             :                (for civil servant only)


                                                                                                                     Page 1 of 5
B. LANGUAGE PROFICIENCY
   1. Academic Aptitude Test (Test Potensi Akademik) if available:

        Score :                 Year :

   2. English Proficiency:

       International (Official TOEFL):            Score :             Year :

       Preparation TOEFL                          Score :             Year :

       Institutional TOEFL                        Score :             Year :
                                                                                                         (Click the arrow
       IELTS                       Overall Band                       Date taken                         and pick the date)

   3. Please indicate (thick) your proficiency in foreign language (s):

                Language                                Spoken                                   Written

       English                            Fair          Good        Very Good       Fair          Good            Very Good

       Arabic                             Fair          Good        Very Good       Fair          Good            Very Good

       German                             Fair          Good        Very Good       Fair          Good            Very Good

       French                             Fair          Good        Very Good       Fair          Good            Very Good

       Dutch                              Fair          Good        Very Good       Fair          Good            Very Good



C. ACADEMIC BACKGROUND
   1. Title of your undergraduate and graduate thesis:

       Title of undergraduate thesis:

       Title of graduate thesis:

   2. Please state your university, field of study, and year of degree obtained
                                                 Year Attended       Degrees/                                    Field
       No.        Name of Institution                                                       Faculty
                                                 From       To      Certification                              of Study

        1.                                                               /

        2.                                                               /

   3. Write your Grade Point Average (Indeks Prestasi Kumulatif, IPK)

         S1 =                      S2 =                     (qualitative or quantitative)

                                                                                                                   Page 2 of 5
D. ACADEMIC WORKS
   1. List of your 5 most recent reserah projects related significantly to your proposed study, and your
      position at the projects:

          No.     Year                          Project Tittle                               Position

           1.


           2.


           3.


           4.


           5.


   2. List of your five (5) most recent relevant books or other scholarly works published in journals:

                                                                                   Publisher or Journal name
          No.      Year                     Tittle of the book/work
                                                                                   and place of publication*)

           1.


           2.


           3.


           4.


           5.

         *) Please separate the name and place with coma (,). Write the year in yyyy format (Ex. 2010)


E. ACADEMIC REFEREE
  Write two (2) names of your academic referees (former advisor, direct academic advisor) for your
  prospectieve study *)
   No.                    Name                           Relationship                 Country
    1.

    2.

  *) For doctorate applicant, one of the referee would be best his/her prospective supervisor.

                                                                                                    Page 3 of 5
F. COURSES AND TRAININGS
  Relevant courses and trainings:
                                                                            Date taken
   No.                          Title                                                              Position
                                                                    From                 To

   1.

   2.

   3.

   4.

   5.

   6.

   7.



G. CURRENT POSITION AND SUITES
  Write your position and responsibilities in your home institution. For teaching staff applicant (dosen), list
  the name of courses you have been teaching since the last two years.
         No.                                         Course/Job Title (s)

          1.

          2.

          3.

          4.

          5.

   2. Administrative or other responsibilities within the past five years:

                         Year                                                 Position

                          to

                          to

                          to

                          to

                                                                                                      Page 4 of 5
H. PROPOSED STUDY PROGRAM

     1.    Field of Study                   :

     2.    Main Research Interest           :
                                                                                        Application for any country other than
     3.    Proposed Country                 :                                           those in the list would not be approved

     4.    Proposed University              :

     5.    Name of Advisor                  :

     6.    Length of Proposed Study         :
                                                 Please attach separately your research proposal you have been
                                                 discussed with or approved by your prospective advisor. Please also
     7.    Research Proposal                :    provide or attache copies of your communication letter or emails with
                                                 your prospective advisor(s).


I. DOCUMENTARY EVIDENCE
    Required documentation: please tick if you have attached the following documents in support of your
    application
                                                                                                              Availability
     No.                                        Name of Document
                                                                                                              Yes    N/A
     1.    Official copies of English-translated academic transcript
      2.   Letter from the head of your home institution confirming your status as permanent
           staff of the institution and that he/she recommends you to apply for the scholarship

     3.    Research proposal

     4.    Valid Passport
     5.    Copy of your Bank Account

     6.    Letters of Recommendation (Academic Referee)

     7.    Letter of Acceptance from proposed university

     8.    Language Proficiency Certificate(s)

     9.    Copies of communication with prospective advisor

     10.   Copies of the page(s) of your works which confirm the date and the place of publication

I declare in submitting this application form that the information contained in it and provided in connection with
this application is true and correct.
             Name                                Signature                 Date

                                                                                       (Click the arrow and pick
                                                                                       the date)


                                                                                                                  Page 5 of 5

				
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