Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Personal Information
Name: _____________________________________________________________________________________________
Citizenship:
__________________________________________________________________________________________
Place and date of birth:
_____________________________________________________________________________
Mailing Address:
____________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________
(Office): ______________________ Fax: _______________________
___________________________________
(Home)/Cell-phone:
_____________________
Email:
Academic History**
University/Institute Attended after High School
Obtained/Expected
GPA/IPK
Years Attended
From
To
Degree
(incl. Field of Study)
____________________________________________________
_________________________
__________________________________ _________
____________________________________________________
_________________________
__________________________________ _________
____________________________________________________
_________________________
__________________________________ _________
Distinction/Honors
____________________ _______________________________________________________________________________
____________________ _______________________________________________________________________________
Standardized Test Scores
(Please attach a photocopy of each test. Test results should not be older than 2 years)
Test
Score
Date taken
Professional History**
List your work experience since university graduation. Start with the most current one.
Dates (ToFrom)
Position
Name of Institution
(indicate month)
Responsibility
Sponsored by
Date
__________________________________
__________________________________
__________________________________
Articles/Books/Unpublished Papers/Thesis/Dissertation**
Title of publication
Subject
Type***
Date
Country
Purpose
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Research Proposal
(for Senior Research Program applicants only)
This section is very IMPORTANT: As part of the evaluation of your application, you are required to attach a
three to five-page Research Proposal. (See below)
Research Proposal (for both Doctoral Dissertation Research and Senior Research
Program)
Project title:
___________________________________________________________________________________________________________________
Status of
__________________________________
__________________________________
_____________________________
__________________________________
__________________________________
_____________________________
Declaration
I hereby certify that the information I have provided on this application form and in any attached materials is
accurate and true to the best of my knowledge and belief, and I agree to notify DIKTI of any change in the above
information or of any further information that might affect my eligibility for consideration as a prospective recipient
of the Fulbright Scholarship award.
I understand that by completing this application form there is no assurance that I will be awarded a grant.
I understand that grant funds are not sufficient to cover travel or support for my family and I will make necessary
arrangements for the living expenses in Indonesia while I am away or in the U.S. if they wish to join me.
I have no objection to publicity about my selection for a Fulbright-DIKTI Scholarship.
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