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					                  UNDERGRADUATE PROGRAM APPLICATION FORM
                  FORMULIR APLIKASI PROGRAM UNDERGRADUATE

                                                                               PERSONAL DATA
                                                                                DATA PRIBADI
Name                                                                                     ID No. / KTP No.                        :
                                    :
Nama                                                                                     Tax ID No. / NPWP No.                   :
Home Address                                                                             Home Phone / Telp. Rumah                :
                                    :
Alamat Rumah                                                                             Cell Phone / No. HP                     :
Postal Address                                                                           Email Address
                                    :                                                                                            :
Alamat Surat Menyurat                                                                    Alamat email
Place & Date of Birth                                                                    Nationality & Religion
                                    :                                                                                            :
                                                                                         Kebangsaan & Agama
Marital & Tanggal Lahir
Tempat Status                                                                            Blood Group
                                    :                                                                                            :
Status Pernikahan                                                                        Golongan Darah
Sex                                                                                      Emergency Contact Person & No.
                                    :                                                                                            :
                                                                                         Berita Darurat Kepada & No.
Jenis Kelamin
                                                                   EDUCATIONAL BACKGROUND ELIGIBILITY
                                                                  KEABSAHAN LATAR BELAKANG PENDIDIKAN
The Undergradute Program of Thiess Contractors Indonesia (TCI) is open to all Indonesian students in their minimum Semester 6 of their study who satisfy the following
selection criteria and requirements as establish and managed by TCI.
Program Undergraduate PT Thiess Contractors Indonesia (TCI) terbuka bagi mahasiswa S1 di Indonesia minimal Semester 6 yang memenuhi kualifikasi dan persyaratan yang
ditetapkan oleh manajemen TCI.

                                        University of Indonesia                                                                      University of Padjajaran
                                        Jakarta                                                                                      Bandung

                                        Bandung Institute of Technology                                                              University of Gadjah Mada
                                        Bandung                                                                                      Jogjakarta

                                        UPN “Veteran”                                                                                University of Airlangga
                                        Jogjakarta                                                                                   Surabaya

University                              Sepuluh November Institute of Technology                                                     University of Diponegoro
Universitas                             Surabaya                                                                                     Semarang

                                        University of Sebelas Maret                                                                  University of Brawijaya
                                        Solo                                                                                         Malang

                                        University of Hasanuddin                                                                     University of Sriwijaya
                                        Makassar                                                                                     Palembang

                                        Other, please specify name of university and its location:
                                        Lainnya, mohon disebutkan nama universitas dan lokasi

                                        Mining Engineering                                                                           Geology Engineering
                                        Teknik Pertambangan                                                                          Teknik Geologis

                                        Industrial Engineering                                                                       Accounting
                                        Teknik Industri                                                                              Akuntansi

                                        Mechanical Engineering                                                                       Management
                                        Teknik Mekanik                                                                               Manajemen

Field of Study                          Electrical Engineering                                                                       Law
Jurusan                                 Teknik Elektro                                                                               Hukum

                                        Environment Engineering                                                                      Psychology
                                        Teknik Lingkungan                                                                            Psikologi

                                        Chemical Engineering                                                                         Occupational Health and Safety
                                        Teknik Kimia                                                                                 Kesehatan dan Keselamatan Kerja

                                        Civil Engineering                                                                            Other, please specify
                                        Teknik Sipil                                                                                 Lainnya, mohon disebutkan

Semester                                                                                 Current Accumulative GPA:
                                    :                                                                                            :
Semester                                                                                 IPK Kumulatif Terakhir
Expected Graduation Date                                                                 Expected Starting Date:
                                    :                                                                                            :
Perkiraan Waktu Kelulusan                                                                Perkiraan Waktu Dapat Mulai Bekerja




2010-03                                                                             Page 1 of 3
                                                                              JOB PREFERENCE
                                                                               MINAT KERJA

                                         Mine Planning                                                  Mine Operation


                                         Drilling & Blasting                                            Procurement


                                         Logistics                                                      Maintenance Planning


                                         Maintenance Operation                                          Data Management


                                         Piping                                                         Geology

Area of work you are interested
                                         Surveying                                                      Environment
Area kerja yang Anda minati

                                         Civil Engineering                                              Coal Processing


                                         Community Relations                                            Industrial Relations


                                         Recruitment                                                    Training & Development


                                         Finance & Administration                                       Tax Accounting


                                         Accounts Payable                                               Payroll


                                                                                  SCHOLARSHIPS
                                                                                    BEASISWA
Have you ever or still obtaining any scholarship from other institution?
                                                                                         Yes       No
Apakah Anda pernah atau sedang menerima beasiswa apapun dari institusi lain?

                                         Sponsoring institution's name
                                                                                         :
                                         Nama institusi pemberi beasiswa

                                         The conditions of scholarship received
                                     1                                                   :
                                         Kondisi dari beasiswa yang diterima

                                         Period
                                                                                         :
                                         Periode
                                         Sponsoring institution's name
                                                                                         :
                                         Nama institusi pemberi beasiswa
If so, please answer next question
                                         The conditions of scholarship received
Jika iya, mohon menjawab             2                                                   :
                                         Kondisi dari beasiswa yang diterima
pertanyaan disamping
                                         Period
                                                                                         :
                                         Periode
                                         Sponsoring institution's name
                                                                                         :
                                         Nama institusi pemberi beasiswa

                                         The conditions of scholarship received
                                     3                                                   :
                                         Kondisi dari beasiswa yang diterima

                                         Period
                                                                                         :
                                         Periode
                                         Company / Institution's Name
                                                                                         :
                                         Nama Perusahaan / Institusi
                                     1
                                         Date of Application
Name of companies or                                                                     :
                                         Tanggal Permohonan
institutions with which you have
pending application for                  Company / Institution's Name
                                                                                         :
scholarships                             Nama Perusahaan / Institusi
                                     2
Nama perusahaan atau institusi           Date of Application
dimana Anda sedang                                                                       :
                                         Tanggal Permohonan
mengajukan permohonan
                                         Company / Institution's Name
beasiswa                                                                                 :
                                         Nama Perusahaan / Institusi
                                     3
                                         Date of Application
                                                                                         :
                                         Tanggal Permohonan




2010-03                                                                              Page 2 of 3
                                                                           GENERAL INFORMATION
                                                                             INFORMASI UMUM
Are you in good health?
                                                                                          Yes       No
Apakah Anda dalam kondisi yang sehat?
If no, why?
Jika tidak, kenapa?

Please state with dates, any serious illness, allergies, operations, disabilities or accidents, you have had!
Mohon sebutkan penyakit serius, operasi/pembedahan, ketidakmampuan atau kecelakaan yang pernah Anda alami beserta
waktunya!

Have you been refused medical coverage?
                                                                                          Yes       No
Pernahkan permohonan asuransi anda ditolak?

Do you take alcohol/drugs?
                                                                                          Yes       No
Apakah Anda menggunakan obat-obatan/alkohol?

If yes, to what extent?
Jika iya, sampai sejauh mana?

Are you involved in any administrative, civil or criminal case?
                                                                                          Yes       No
Apakah Anda pernah tersangkut kasus kriminal, perdata, administratif?

Have you ever been convicted in a court of law?
                                                                                          Yes       No
Apakah Anda pernah divonis pengadilan?

If so, give details!
Jika ya, mohon jelaskan!

Do you have any other source of income?
                                                                                          Yes       No
Apakah Anda memiliki sumber penghasilan lainnya?

If so, give details!
Jika ya, mohon jelaskan!


                                                                                  REFERENCES
                                                                                   REFERENSI
         Name of Referee                           Relationship with Referee                        Organization and Position                 Phone No and Email Address
      Nama yang Direferensikan                     Hubungan Dengan Referee                            Organisasi dan Posisi                 Nomor Telepon dan Alamat Email




Notification to Candidate
Perhatian kepada Pelamar

• You will not be charged any money or required to perform any service to Thiess or any of its employees in this selection process of TCI Undergraduate Program.
  Anda tidak dipungut bayaran berupa uang atau diminta untuk memberikan jasa kepada Thiess atau Karyawan dalam proses seleksi Program Undergraduate TCI.
• If you are requested to pay a fee or perform a service, please report the name of the person, the title of the job you were interviewed for or seeking to be hired
  for, the date and location where the incident occurred.
  Jika Anda diminta untuk membayar sejumlah uang atau memberikan jasa, silahkan melaporkan nama orang tersebut, posisi pekerjaan yang Anda diwawancarai
  atau posisi yang Anda lamar, tanggal dan lokasi dimana hal tersebut terjadi.


I hereby declare that the information provided here in to be true and correct. I have executed this application form for scholarship program and refer you to the person
whose names are listed for further information as to my character, ability and verification of matters stated herein. I understand that, if I am accepted in the Undergraduate
Program of TCI, my education and experiences will be verified and that any false information on this form is ground for immediate termination of my scholarship.

Dengan ini saya menyatakan bahwa keterangan yang saya berikan diatas adalah benar dan jujur. Saya telah melaksanakan apa yang diminta dalam formulir aplikasi untuk
program beasiswa ini dan mempersilahkan Anda untuk menghubungi orang yang namanya tercantum disini sebagai referensi keterangan lebih lanjut mengenai watak,
kesanggupan saya dan untuk membuktikan apa yang tertera disini. Saya mengerti bahwa, jika saya diterima dalam Program Undergraduate TCI, pendidikan dan pengalaman
saya akan diselidiki kebenarannya dan bahwa keterangan palsu dalam formulir ini merupakan alasan kuat untuk menghentikan beasiswa seketika.

________________, ___________________________________________




____________________________
 Name & Signature
 Nama jelas & Tanda Tangan




2010-03                                                                              Page 3 of 3

				
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