Scholarship in honour of Their Royal Highnesses The Duke and Duchess of Cambridge Application Form

PERSONAL INFORMATION: Surname Forename(s) Title Date of Birth Country of Birth Nationality Home Address City, State/Province Country Post/Zip/Region Code Telephone Number Email Address HERIJON Mr Day:21 INONESIA INDONESIA JALAN LINTAS DURI-DUMAI KM.20 DURI RIAU INDONESIA 28884 +6282171363432 sword_deck@yahoo.com Month: 08 Year:1993

EDUCATION: High School/College/University SMA 2 MANDAU Type of Qualification NATIONAL EXAM Level SECOND ARY (HIGH SCHOOL ) FIRST (HIGH SCHOOL ) ELEMEN TARY SCHOOL Subject Examination Year 2011

SMP 3 MANDAU

NATIONAL EXAM

2008

SD 27 SEBANGAR

NATIONAL EXAM

2005

COURSE OF STUDY: University of St Andrews ID Number (if known) What course(s) of study do you intend to take at the University of St Andrews?

PERSONALSTATEMENT:
Please write a statement of motivation in support of your application(not more than 200 words). Include your reasons for applying forthe Scholarship, explain how you would expect to benefit from the opportunities the award provides,and describe how you think you might contribute to St Andrews during your time here. You might also wish to mentionactivities or personal qualities that you consider particularly relevant to your application.

FINANCIAL STATEMENT:
Please provide a statement outlining your financial need (not more than 100 words)

I EXAM FROM SECONDARY HIGH SCHOLL ON APRIL 2011, I CAN NOT TO CONTINUE MY STUDY IN UNIVERSITY BECAUSE I DONT HAVE MONEY. I HAVE 2 SISTER, THEY A STUDENT OF SECONDARY HIGH SCHOOL AND ELEMENTARY SCHOOL AND MY FATHER ONLY WORKER IN MY VILLAGE. I HAVE SPIRIT, I HAVE LONGING BUT FINANCIAL PROBLEM ONLY, I CAN NOT REAL MY DREAM I AM DESIROUS OF BETTER FACILITIES IN MY VILLAGE, MAKE A CHANGE TO BETTER LIFE FOR THE PEOPLE.

REFERENCES: Please provide 2 references; both an academic and personal letter of recommendation. Each reference should be not more than 200 words. The academic reference could be from ateacher, college counsellor or someone who knows your academic capabilities well. The personal reference should be given from a non-family member who will serve as a personal character reference.For example an academic advisor who is aware of your personal attributes, a current or former employer, senior staff member in an organisation where you have volunteered. ACADEMIC REFERENCE: Name of referee Position School/College/University Telephone Number Email Address

PERSONAL REFERENCE: Name of referee Position Organisation Telephone Number Email Address

DECLARATION: I sign below to confirm that all information given is full and accurate and that I have read and understood the notes and guidelines on this application form, and agree to comply with any conditions associated with the offer of an award.

Signature: HERIJON MUHAMMAD SYAHRIL Date:

Please check all parts of this application form have been completed before submission. To submit an application please email this form to scholarships@st-andrews.ac.uk and include Scholarship in honour of Their Royal Highnesses The Duke and Duchess of Cambridge in subject line. All applications received, at this email address, by the closing date will be considered.